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

You requested coverage for Hydroxyzine Hydrochloride 25 milligram tablets prescribed daily for sleep disturbance. 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. 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 Hydroxyzine Hydrochloride for sleep disturbance. In review of the Medicare approved compendia, sleep disturbance is not a medically accepted indication for Hydroxyzine Hydrochloride. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Hydroxyzine Hydrochloride at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Octreotide Acetate 50 micrograms/milliliter injection prescribed three times daily for chronic diarrhea secondary to short gut 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Octreotide Acetate to treat your chronic diarrhea secondary to short gut syndrome. 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 Octreotide Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vraylar 1.5 milligram oral capsule prescribed daily for major depressive disorder, recurrent severe without psychotic features. The Part D plan denied your request because 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 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. At initial determination and redetermination the diagnoses of major depressive, recurrent severe without psychotic features, generalized anxiety disorder and insomnia were given. At reconsideration, the diagnosis of bipolar disorder was given. No medical records were provided by the prescriber to support the change in diagnoses. 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 Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine HCL 10 milligram tablets prescribed three times daily for skeletal muscle spasm not related to an acute musculoskeletal condition, chronic pain syndrome, and muscle spasms at multiple sites. 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 Cyclobenzaprine HCL to treat your skeletal muscle spasm not related to an acute musculoskeletal condition, chronic pain syndrome, and muscle spasms at multiple sites. 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 Cyclobenzaprine HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Myrbetriq ER 25 milligram tablets prescribed daily for overactive bladder, radiation effects after uterine cancer, and chronic hematuria. 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. Myrbetriq ER is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

You requested Fentanyl Patch 25 microgram/hour prescribed to treat chronic pain 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 reviewed all documentation submitted. This includes any information submitted at the reconsideration level. Medicare approved compendia indicate that treatment of chronic pain in opioid tolerant patients is an acceptable indication. The provider submitted a statement and progress note detailing the diagnosis, evaluation, and medical assessment of pain, past and current treatments of pain underlying or co-occurring disorders and conditions, effect of the pain on physical and psychological functioning findings. The provider also indicates that the patient has received risk assessment and pain management. A physician reviewed your appeal and determined that the plan is required to cover Fentanyl Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch to treat the diagnosis of myalgia. 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 use of the requested drug to treat the provided diagnoses 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 the enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined the plan is not required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Colistimethate sodium (CBA) 150 milligram nebulizer solution prescribed as directed for cystic fibrosis with pulmonary manifestations, and Methicillin resistant Staphylococcus aureus infection. 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 Colistimethate sodium (CBA) to treat your cystic fibrosis with pulmonary manifestations, and Methicillin resistant Staphylococcus aureus infection. However, the Medicare approved compendia do not support the use of this drug for your condition. The following citation was referenced in DrugDex, a Medicare approved compendia: Colistimethate is not Food and Drug Administration (FDA) approved for inhalation via nebulizer; a case of acute respiratory failure and subsequent death of a patient with cystic fibrosis who received premixed colistin via nebulization has been reported. Non- FDA approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.A physician reviewed your appeal and  determined that the plan is not required to cover the Colistimethate sodium (CBA).
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Erythromycin 2% gel to treat acne vulgaris. 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 Esomeprazole Magnesium DR 40 milligram capsules. 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 indicates that Esomeprazole Magnesium DR capsules have been prescribed to treat gastroesophageal reflux disease. For coverage of this medication, the Part D plan has a step therapy requirement. The plan requires that two formulary alternatives be tried and failed first, or are contraindicated, before coverage of Esomeprazole Magnesium will be granted. The submitted medical records do not support that the step therapy requirements have been met. A physician reviewed your appeal and determined that the plan is not required to cover the Esomeprazole Magnesium DR capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol Sulfate Solution 2.5 milligram/3 milliliter. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. The records submitted were insufficient to determine if the drug is being used for a medically accepted indication. The documentation did not include a diagnosis or any medical records. A physician reviewed your appeal and determined that the plan is not required to cover Albuterol Sulfate Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cequa 0.09 percent ophthalmic solution prescribed as directed for severe dry eye. 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 requested drug is being provided by your plan under a formulary exception. Cequa 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 non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 97 milligram to 103 milligram oral tablet. 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 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The prescriber statement and medical records indicate Entresto was prescribed to treat valvular cardiomyopathy. The Medicare approved compendia do not support the use of this drug for your condition. 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 your appeal and determined that the plan is not required to cover Entresto.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ambien 10 milligrams prescribed as directed 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. 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 Ambien.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Travoprost 0.004% eye drops to treat glaucoma. The Part D plan denied the 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 plan limits the amount of Travoprost 0.004% eye drops to 7.5 milliliters per 75 days. The prescriber indicated that the number of doses of the requested drug allowed by the plan would be effective in treating the enrollees condition. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aripiprazole 10 milligram tablets. This case was auto-forwarded.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The documentation indicates that Aripiprazole is prescribed to treat major depressive disorder. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition(s) due to not being supported as an adjunctive treatment. A physician reviewed your appeal and determined that the plan is not required to Aripiprazole.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cosentyx 150 milligram/milliliter pen injector to treat psoriasis vulgaris. 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 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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug. 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 Ciclopirox Solution 8%. 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 indicates that Ciclopirox Solution is prescribed to treat onycomycosis with lunula involvement. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition(s).A physician reviewed your appeal and determined that the plan is not required to Ciclopirox Solution.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Repatha Sureclick 140 milligram/milliliter prescribed as directed for hyperlipidemia. 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 level.The medical records show you were prescribed Repatha Sureclick to treat your condition. The records provided do show your cholesterol levels have decreased since being on treatment. Prior to starting treatment your lab results dated November 3, 2020, show your low-density lipoprotein (LDL) levels were 144. Your lab results dated March 16, 2021, show your LDL levels were less than 129. Therefore, the plans coverage criteria has been met and the drug can be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 micrograms inhaler with device prescribed daily for chronic obstructive pulmonary 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. We also researched Medicare systems and reviewed the enrollment data available. The prescriber has not indicated 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. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Anoro Ellipta.A physician reviewed your appeal and  determined that the plan is not required to cover the Anoro Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 3% Gel to treat spondylosis with radiculopathy lumbosacral region. 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

At issue is Contrave ER 8 milligram-90 milligram tablets to treat the diagnosis of obesity. 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.Drugs used for weight loss are excluded from coverage under Medicare Part D.A physician reviewed the appeal and  determined that the plan is not required to cover Contrave.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Doxycycline Monohydrate 100 milligram oral capsule prescribed twice daily for rosacea, unspecified. The Part D plan denied your request for a tiering exception. We received an auto-forwarded reconsideration request from the coverage level. 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 asked your prescriber to send us information about your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why similar medications on the lower tiers would not work for you.  However, we did not receive the documentation.Doxycycline Monohydrate is a generic drug on Tier 3 of the plans formulary. The plans formulary includes Minocycline which is the same class as Doxycycline Monohydrate, on Tier 2. Your doctor did not address why the Minocycline would not work for you. All generic drugs on lower tiers have not been tried. 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 Diclofenac Epolamine patch 1.3% prescribed daily for spinal stenosis of cervical region and low back pain. The Part D plan denied your request because 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 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 Diclofenac Epolamine patch was prescribed to treat cervical pain due to spinal stenosis. However, the Medicare approved compendia do not support the use of this drug for this condition. 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 your appeal and determined that the plan is not required to cover Diclofenac Epolamine patch 1.3%.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prolia 60 milligrams/milliliter injection prescribed as directed for age-related osteoporosis without current pathological fracture and unilateral primary osteoarthritis right hip. 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. Prolia is a biologic drug on Tier 4 of the plans formulary. There are no biologic drugs of the same type on the lower cost sharing tiers. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.