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

At issue is methlyphenidate 10 milligrams prescribed for significant daytime hypersomnia. 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 available. A physician reviewed your appeal and determined that the plan is not required to cover the methlyphenidate because significant daytime hypersomnia is not a medically accepted indication to use this drug. At reconsideration a diagnosis of obstructive sleep apnea was given. No medical records were provided by the prescriber to support this diagnosis. However, this is also not a medically accepted indication for this drug.The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition(s). Therefore the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, the requested drug does not meet the definition of a Medicare Part D drug and is therefore not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Monurol 3 milligram granule packets prescribed for the prevention of urinary tract infections. The Part D plan denied your request as not medically indicated. 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.Monurol is being requested to prevent urinary tract infections. 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 Monurol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxychloroquine 200 mg tablet to treat undifferentiated connective tissue disorder.  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 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 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 the enrollees condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trintellix 20 milligram tablets prescribed daily for depression. The Part D Plan denied your request for a tiering exception. 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. Trintellix 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. 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 coverage for Livalo 2 milligram tablet prescribed for hyperlipidemia. 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 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 record shows Livalo is being prescribed for hyperlipidemia. The Medicare approved compendia supports the use of the requested drug for your condition. However, the drug is not one that is covered on your plan's formulary or their list of covered drugs. You did not indicate that all covered Part D drugs on any tier of the plan's formulary would not be as effective for the enrollee as the requested non-formulary drug, and/or would have adverse effects.The plan is not required to cover the drug at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocodone-Acetaminophen 10/325 milligrams tablet, quantity 90 for 30 days. 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. Hydrocodone-Acetaminophen 10/325 milligrams is a generic drug on Tier 3 of the plan's formulary.The prescriber has not indicated why other 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, a tiering exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover the drug for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate HCL 10 milligram tablets prescribed as directed for multiple sclerosis. The Part D plan denied your request because the requested drug 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 Methylphenidate HCL 10 milligram tablets to treat your multiple sclerosis. 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 drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine-prilocaine 2.5% cream prescribed as a numbing agent for chemotherapy access management due to malignant neoplasm of the right breast. The Part D plan denied your request because this drug is not 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 record shows you are using the lidocaine-prilocaine cream as a numbing agent for chemotherapy access management due to malignant neoplasm of the right breast. The Medicare approved compendia do not 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 plan is not required to cover the Lidocaine- prilocaine cream because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zolpidem Tartrate 10 milligrams prescribed two capsules at bedtime for insomnia. Your Part D plan denied the request because the quantity ordered exceeded the amount allowed. 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. Your medical records show your doctor prescribed Zolpidem Tartrate to treat your insomnia. The Medicare approved compendium does support the use of Zolpidem Tartrate for your condition. However, an exception to the plans coverage criteria is not supported by the documentation submitted.Our Physician Reviewer's opinion is that the quantity limit exception is not met per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clobazam 10 milligrams 1.5 tablets to be given two times a day for generalized epileptic seizures. The Part D plan denied the drug because it was not medically necessary. 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.Clobazam is being requested to treat generalized epileptic seizures. The prescriber states the enrollee has Lennox-Gastaut syndrome but the medical records do not support this diagnosis. 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 the Clobazam.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuzyra 300 milligrams prescribed for urinary tract infection. The plan denied the request. 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 Nuzyra for your urinary tract infection. This drug is not listed in your plans formulary for your condition. Additionally, Medicare Part D compendia do not support the use as a medically accepted indication. Therefore, the requested drug cannot receive a formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover Nuzyra because the documentation does not support a medically accepted indication for Nuzyra.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Entresto (Sacubitril/Valsartan) 24-26 milligrams prescribed twice daily for cardiomyopathy. You asked the Part D plan to provide a cost-sharing tiering exception. The plan denied the appeal because there are no brand name drugs of the same type in the lower cost-sharing tiers that treat your condition. 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 Entresto for your cardiomyopathy. A Medicare approved compendium supports the use of the requested drug for your condition. Entresto is a brand name drug on Tier 3 of your plan's formulary. There are no brand name drugs of the same type on the lower cost-sharing levels. Therefore, the requested drug is not eligible for a cost-sharing tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Entresto because there are no brand name drugs of the same type in the lower cost-sharing tiers.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Clonidine 0.2 milligram 24 hour transdermal patch prescribed daily for hypertension. The Part D Plan denied your request for a tiering exception because the prescriber did not explain why all the alternative drugs in a lower tier would not work as well. 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. Your physician submitted a supporting statement. The physician had prescribed clonidine oral tablet prior to ordering the transdermal patch. The physician states the tablet produced side effects and an inconsistent blood pressure resulting in uncontrolled hypertension. Clonidine 0.2 milligram 24 hour transdermal patch is a generic drug on Tier 4 of the plans formulary. The prescriber statement shows the oral tablet was tried with poor results. The plans formulary does not include generic alternatives of the same type to treat your condition on a lower tier.A physician reviewed your appeal and determined that the plan is required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latuda 20 milligram tablets prescribed daily for bipolar disorder. The Part D plan denied your request for a tiering exception because the drug you requested is in the specialty tier; drugs placed in the specialty tier are not eligible for tiering exceptions. 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 being provided by the plan at the cost sharing level of the specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Latuda 20 milligram tablets  because a tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tacrolimus 1 milligram capsule prescribed to prevent transplant rejection. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows the enrollee had a kidney transplant on February 18, 2016. According to Medicare enrollment records, the enrollee was entitled to Medicare Part A coverage at the time of the transplant. Therefore, the transplant is considered a Medicare covered transplant and Tacrolimus is eligible for coverage under Medicare Part B. Medicare Part B covers prescription drugs used in immunosuppressive therapy furnished to an enrollee who has received an organ transplant. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. We determined that the Medicare Part D plan is not required to cover Tacrolimus. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit. Please submit this request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vyvanse 50 milligrams prescribed one capsule every morning for major depression recurrent, severe, without psychotic features. The Part D plan denied your request because diagnosis provided does 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 medical records show your doctor prescribed Vyvanse to treat your major depression. 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 the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sumatriptan Succinate 100 milligram tablets prescribed as 18 tablets per 30 days. The Part D plan denied the request stating that the provider did not provide a diagnosis and there were no Food and Drug Administration approved indications found for the amount of the drug requested. We received a reconsideration request from the plan. 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. The physician has not submitted the enrollees diagnosis. The documentation was insufficient to determine if the drug and amount requested are medically indicated per Medicare approved compendia. 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 Sumatriptan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mayzent (Siponimod) 2 milligram tablets prescribed daily for multiple sclerosis. The Part D plan denied your request for a tier change request because Mayzent is in the specialty tier of your list of covered drugs. The drug was approved for coverage on January 30, 2021, at Tier 5. 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 also researched Medicare systems and reviewed the enrollment data available. The record shows Mayzent is being prescribed for multiple sclerosis. The Medicare approved compendia, supports the use of the requested drug for your condition. The plan shows Mayzent is a brand name Tier 5 drug. Your plan does not allow you to receive drugs in this tier at a lower cost share.Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Memantine Hydrochloride 5 milligram, 5 milligrams daily for 28 days followed by 10 milligrams daily for 21 days, for dementia. The Part D plan denied the request stating non-formulary criteria were not met. 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.This drug is clearly on this plans formulary. The diagnosis of dementia (non-Alzheimer) and memory loss is an off-label use in the Medicare compendia, and therefore considered a medically accepted indication. The Medicare approved compendia do support the use of the drug for the enrollees condition. Therefore, the drug is eligible for coverage under Medicare Part D. There are prior authorization criteria for which an exception is granted.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 Mirapex .75mg ER tablet to treat restless legs syndrome.  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 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

At issue is Tadalafil 10 milligram tablets prescribed daily to treat primary malignant neoplasm of prostate and bladder. 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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not FDA approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Freestyle flash system kit. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. 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. We also researched Medicare systems and reviewed the enrollment data available.Based on the information provided, we determined the requested device may be eligible for coverage under Part B under Medicare rules. A physician reviewed the appeal and determined that the requested device is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pomalyst 4 milligrams prescribed one capsule for new diagnosis of multiple myeloma. The Part D plan denied your request because diagnosis provided does not meet the requirements of a Food and Drug Administration 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. Your medical records show your doctor prescribed Pomalyst to treat your new diagnosis of multiple myeloma. However, the Medicare approved compendium does not support the use of this drug for your condition. Your doctor has not shown that you have received at least two prior therapies for multiple myeloma, including an immunomodulatory agent and a proteasome inhibitor.A physician reviewed your appeal and determined that the plan is not required to cover Pomalyst because your diagnosis does not meet the Medicare requirement of a medically accepted indication.