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

At issue is Tranexamic Acid 650 milligram prescribed three times a day to treat thrombocytopenia.  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.  Your medical records show your doctor prescribed Tranexamic Acid to treat thrombocytopenia. 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 Tranexamic Acid. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
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 because it does not meet the criteria of a medically accepted indication. 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 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 550 milligram tablets 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 Xifaxan 550 milligram tablets because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Voriconazole 200 milligram tablets prescribed for prevention of a fungal infection in an enrollee with a severely immunocompromised state. The Part D plan denied the request. We received an expedited reconsideration request. We performed and 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 medication for the diagnosis submitted. Therefore, it is ineligible for coverage under Medicare Part D.   A physician reviewed your appeal and determined that the plan is not required to cover Voriconazole.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Parsons Solution (compounded bladder irrigation of Heparin, Lidocaine, and Sodium Bicarbonate) prescribed for interstitial cystitis. The Part D plan denied your request because the requested compounded product was not a Medicare Part D eligible product. 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 information submitted at the reconsideration level. This drug is a compounded drug. Therefore, we reviewed each ingredient individually. Lidocaine powder and Heparin powder are bulk products.  Bulk products are not FDA approved drugs and are therefore not covered by Part D.   Sterile water solution for irrigation and Sodium Bicarbonate are non-active ingredients and are therefore not Part D drugs.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tacrolimus 0.1% ointment prescribed as directed for seborrheic dermatitis. The Part D plan denied your request for a drug that requires prior authorization because the drug 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 documentation shows the doctor prescribed Tacrolimus ointment for seborrheic dermatitis. 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 Tacrolimus ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Valganciclovir HCl 450 milligram tablets prescribed four times daily for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue is on a specialty tier and is not eligible for a lower cost-sharing tier. 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 information submitted at the reconsideration level.Valganciclovir HCl is on the specialty tier (Tier 5) of your plans formulary. Drugs that are on the plans specialty tier 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 Nuedexta 20/10 milligrams prescribed twice daily for pseudobulbar affect secondary to cerebral infarction. The Part D plan denied coverage. The plan requires prior approval before covering some 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 plan requires the pseudobulbar affect to be secondary to amyotrophic lateral sclerosis or multiple sclerosis 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 Nuedexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cimzia, 400 milligrams per 2 milliliters syringe kit, 200 milligrams to be given subcutaneously every 14 days for psoriatic arthritis. The Part D Plan denied your request for a lower-cost tiering exception because the medication is not included on the plans formulary. 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. A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.Cimzia is not included on the plans formulary. The plan does not grant tiering exceptions to non-formulary drugs. Therefore, the Cimzia is not eligible for coverage at a lower-cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate HCl 20 milligram tablets prescribed three times daily for multiple sclerosis related fatigue. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. 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 information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Methylphenidate HCl for multiple sclerosis related fatigue. The Medicare approved compendia do not support the use of the drug for your condition. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Riluzole 50 milligram tablets prescribed twice daily for ataxia. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. 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 information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Riluzole for ataxia. The Medicare approved compendia do not support the use of the drug for your condition. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fanapt 10 mg prescribed twice daily for schizophrenia. The Part D plan denied your request for a tiering exception because the prescriber did not address all alternatives were tried and failed. 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 information submitted at the reconsideration level.Fanapt is a brand drug on Tier 5 of the plans formulary. We requested a supporting statement and medical records from the physician. The documentation does not satisfy the Plans coverage criteria because all brand 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 Lynparza 150 milligram tablet prescribed for soft tissue sarcoma of the left lung with JAK2 positivity. The Part D plan denied your request because the medication is 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 records show you prescribed Lynparza to treat the enrollees lung sarcoma with JAK2 positivity. However, the Medicare approved compendia and Medicare approved journals do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Lynparza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol Sulfate 25 milligram per 3-milliliter nebulizer solution prescribed for acute upper respiratory infection. The Part D plan denied your request to cover the medication under Part D. 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 other information submitted at the reconsideration level.The record shows that your doctor prescribed Albuterol Sulfate because you have an acute upper respiratory infection. The drug is being administered to you via a nebulizer and you are not residing in a skilled nursing facility/ long-term care facility. Medicare rules indicate that a drug prescribed to a Part D eligible individual cannot be considered a covered Part D drug if payment for the drug is or would be available under Medicare Part A or Part B.As such, the drug is eligible for coverage under Part B and is excluded from coverage under Part D. Therefore, the plan is not required to cover the Albuterol Sulfate. 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

You requested Calcipotriene 0.005% Cream prescribed for localized scleroderma (morphea). The Part D plan denied your request because the diagnosis provided did not meet the requirements of a Food and Drug Administration medically accepted indication. 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 information submitted at the reconsideration level. Your records show your doctor prescribed Calcipotriene 0.005% Cream to treat your localized scleroderma (morphea). However, the Medicare approved compendium 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 Calcipotriene 0.005% Cream because your diagnosis does not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Everolimus 0.5 milligram tablets prescribed daily for chronic kidney disease. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. 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 information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Everolimus 0.5 milligram tablets daily to treat your chronic kidney disease. 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 Everolimus 0.5 milligram tablets because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Humira 40 milligram/0.4 milliliter Pen Injector prescribed to treat the enrollees Crohns disease. The Part D plan denied the request for a tiering exception. 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.Humira is a brand biologic on Tier 4 of the plans formulary. There are no brand biologics of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this biologic is not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cosentyx 300 milligram injection prescribed every week for five weeks then every four weeks for hidradenitis suppurativa. The Part D plan denied your request because the off-label use of this drug for this condition is not medically accepted. 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 information submitted at the reconsideration level.Cosentyx was ordered to treat the enrollees condition. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Cosentyx.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 3% gel prescribed for the enrollees condition. The Part D plan denied your request. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read all documentation submitted.The documentation included the diagnosis of acquired flat foot. However, the Medicare approved compendia do not support the use of this drug for this condition.A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Sodium.
Appeal type: Prescription Drug
Decision: Favorable

You requested Auryxia 1 gram tablet prescribed for end stage renal disease; hyperparathyroidism. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. 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 information submitted at the reconsideration level. The submitted documentation indicates your doctor stated your diagnosis is chronic kidney disease, on hemodialysis with secondary hyperparathyroidism.. The Medicare approved compendia do support the use of this drug for your condition. As the drug was  prescribed for a medically accepted indication, coverage is allowed.A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Emgality pen injector to treat migraines. 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 reviewed all documentation submitted.The documentation does not satisfy the plans coverage criteria. There are no medical records from the prescriber to sufficiently addressed the plans coverage criteria and indicate why all alternatives required by the plan 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 Oxycontin 40 milligram tablets prescribed for chronic low back pain. The Part D plan denied your request. 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. Your physician submitted a supporting statement. The supporting statement did not support all alternative formulary medications to treat your condition were tried and failed. A physician reviewed your appeal and determined that the plan is not required to cover Oxycontin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tacrolimus one milligram prescribed two capsules every 12 hours for post-transplant. The Part D Plan denied the request because the prescriber did not provide the detailed information necessary to cover this drug for a prior authorization. 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 information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We determined that the drug is eligible for Part B coverage. The beneficiary had a Medicare-covered transplant on May 31, 2006. Therefore, the drug can be considered for payment under the Part B benefit.Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.  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 Forteo. The Part D plan denied coverage. 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 reviewed your appeal carefully. We reviewed all documentation available. The documentation supports the drug was prescribed for the enrollees diagnosis of osteoporosis. However, the enrollee does not satisfy the plan's prior authorization coverage criteria. There were no medical records provided to determine if coverage criteria were satisfied.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 Votrient 200 milligrams prescribed for malignant neoplasm of thymus and history of metastatic thyroid carcinoma. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization requirements be met 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 information submitted at the reconsideration level. Your medical records show your doctor prescribed Votrient to treat your condition. The Medicare approved compendia do support the use of this drug for your diagnosis. However, the documentation provided does not show the enrollee has satisfied the plan's prior authorization criteria. A physician reviewed your appeal and determined that the plan is not required to cover Votrient.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Azathioprine 50 milligrams daily prescribed for chronic bronchitis. The Part D plan denied your request because the Food and Drug Administration has not approved the use of this drug for the diagnosis provided. 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 information submitted at the reconsideration level. Your medical records show your doctor prescribed Azathioprine to treat chronic bronchitis. 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 Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligrams per milliliter requested to treat the enrollees condition. The Part D plan denied the request because medical necessity was not established. As well, the requested drug has prior authorization criteria. 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. A request was submitted to the prescriber to provide a diagnosis to address the prior authorization criteria and to provide supporting medical records. A reply from the prescriber was not received with the required information. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.