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

You requested Diclofenac Sodium 1% gel prescribed for other chronic pain. 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 originally prescribed Diclofenac Sodium for other chronic pain. In the request for reconsideration, your doctor indicated you have osteoarthritis.  Relevant medical records were requested.  However, no medical records were submitted to verify the change in diagnosis to a medically accepted indication. The Medicare approved compendia do not support the use of this 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 Xeljanz 5 milligram tablet to treat the diagnoses of alopecia areata. 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 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.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 Gralise 300 milligram tablet. The Part D plan denied your request because you did not have a medically accepted indication for this drug. We received an expedited 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 documentation indicates that Gralise is prescribed to treat myofascial pain and for intervertebral disc degeneration of the lumbosacral region. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees conditions.A physician reviewed your appeal and determined that the plan is not required to cover Gralise.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Rocklatan 0.02-0.005% eye drops. The Part D plan denied your request for a tiering exception because there were no other similar drugs on 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.Rocklatan is a brand drug on Tier 2 of your plans formulary. There are no brand drugs of the same type on the lower cost sharing tier. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. Therefore, a tiering exception cannot be granted for the Rocklatan.A physician reviewed your appeal and determined that the plan is not required to cover the Rocklatan at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Arcalyst 120 milligrams per 2 milliliter, 220 milligrams to be given subcutaneously weekly for Adult-Onset Stills disease. The Part D plan denied the drug as not medically necessary. 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 records submitted at the reconsideration level.Arcalyst is being requested to treat Adult-Onset Stills disease. 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 Arcalyst.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Xifaxan 550 milligram tablets prescribed for small intestinal bacterial overgrowth. 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 Xifaxan for small intestinal bacterial overgrowth.In review of the Medicare approved compendia, small intestinal bacterial overgrowth  is not a medically accepted indication for Xifaxan. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Xifaxan at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsules prescribed for circadian rhythm sleep disorder. 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. The prescriber did not respond to a request for addition information. Therefore, the prior authorization requirements were not met.   Our Physician Reviewers opinion is that the plan is not required to cover Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azathioprine 50 milligram tablets prescribed for the treatment of sarcoidosis with uveitis and polyarthralgia. The Part D plan denied your request because the provided diagnoses do 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. 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 your appeal and determined  that the plan is not required to cover Azathioprine because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cayston 75 milligrams nebulized solution prescribed for the treatment of bronchiectasis and chronic pseudomonas aeruginosa pulmonary infection. The Part D plan denied your request because the provided diagnoses do 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. 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 your appeal and determined  that the plan is not required to cover Cayston because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Azathioprine 50 milligram tablets prescribed for sarcoidosis. 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 Azathioprine for sarcoidosis. In review of the Medicare approved compendium, sarcoidosis is not a medically accepted indication for Azathioprine. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Azathioprine at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Dextroamphetamine/Amphetamine 10 milligram tablets prescribed for multiple sclerosis with malaise and fatigue. 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 Dextroamphetamine/Amphetamine for multiple sclerosis with malaise and fatigue.In review of the Medicare approved compendia, vasculitis is not a medically accepted indication for Dextroamphetamine/Amphetamine. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Dextroamphetamine/Amphetamine at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil citrate 20 milligram tablets prescribed for pulmonary hypertension. 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. We also researched Medicare systems and reviewed the enrollment data available. The documentation shows Sildenafil citrate was prescribed by the physician to treat pulmonary hypertension 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 Sildenafil citrate. The drug at issue has not been prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone HCl 20 milligram tablets prescribed for chronic pain. 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 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 supporting statement did not indicate all formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Oxycodone HCl.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Symbicort 80/4.5 inhaler prescribed daily for asthma. The Part D plan denied your request for a tiering exception because Symbicort is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. 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 Symbicort is being prescribed for asthma. The Medicare approved compendia supports the use of the requested drug for your condition. The plan shows Symbicort is a brand name Tier 3 drug. 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 tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Imbruvica 280 milligram tablets prescribed for diffuse large B-cell lymphoma. The Part D plan denied your request for a tier change request because Imbruvica is in the specialty tier of your list of covered drugs. 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 plan shows Imbruvica 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: Unfavorable

You requested coverage for non-formulary Lotemax 0.5% ophthalmic gel for provided diagnoses of primary open-angle glaucoma, left eye, moderate stage; primary open-angle glaucoma, right eye, severe stage; chronic iridocyclitis, bilateral. The Part D plan denied the request stating that the medication was prescribed for 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. Medical records were requested and received from the physician during this reviewThe 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 your appeal and determined that the plan is not required to cover the Lotemax 0.5% ophthalmic gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Solifenacin Succinate 5 milligram tablets. The Part D plan denied your request because the medication was not included on the plans formulary and 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 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 supports that Solifenacin Succinate has been prescribed to treat the enrollees symptoms of urinary frequency, urgency, and nocturia consistent with overactive bladder. However, the prescriber has not sufficiently addressed why all alternative drugs included in the plan to treat this condition have been tried and failed or would likely not be as effective as the requested drug or would likely cause adverse reactions or other harm. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sumatriptan Succinate 6 milligrams per 0.5 milliliter prefilled syringe prescribed twice daily for intractable episodic cluster headaches. The Part D plan denied your request because the information did not support the quantity limit exception. 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.Sumatriptan Succinate is ordered two times per day to treat your intractable episodic cluster headaches. The plan has a quantity limit of 8 per 30 days. The documentation does not support an exception to the quantity limit criteria was met. Therefore, the plan is not required to cover the requested quantity of Sumatriptan Succinate 90 pens per 30 days.A physician reviewed your appeal and determined that the plan is not required to cover the Sumatriptan Succinate, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine HCl 2 milligram sublingual tablets prescribed for spinal stenosis of lumbar region without neurogenic claudication. 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 originally prescribed Buprenorphine HCl for spinal stenosis. Your doctor submitted a statement to indicate the drug at issue was for opioid dependence; however, the medical records submitted do not support the change in diagnosis. The Medicare approved compendia do not support the use of this 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 coverage for Oxbryta 500 milligram tablets. 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 indicates that Oxbryta is being prescribed to treat the enrollees sickle cell disease. As outlined in the Medicare approved compendia, the accepted use of this drug requires that the patient has experienced at least one sickle cell crises (i.e., medical facility visit for sickle cell-related pain, chest syndrome, priapism, or splenic sequestration) in the previous 12 months; is not receiving chronic, prophylactic blood transfusion therapy at the same time; and has a current hemoglobin concentration less than or equal to 10.5 grams per deciliter.The medical records do not support that the enrollee has experienced at least one sickle cell crises (i.e., medical facility visit for sickle cell-related pain, chest syndrome, priapism, or splenic sequestration) in the previous 12 months. Therefore, the documentation does not support that the medication is being prescribed for a medically-accepted indication, and 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 Oxbryta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil 20 milligram tablets (one to five tablets as directed) prescribed as directed for erectile dysfunction. The Part D plan denied your request because drugs being used for the treatment of erectile dysfunction are excluded from coverage by Medicare Part D. 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 determined that the plan is not required to cover Sildenafil. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Daliresp 500 micrograms to treat chronic obstructive pulmonary disease. 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 documentation satisfies the plans coverage criteria. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gammaked Solution 10 grams per 100 milliliters to treat encephalitis and encephalomyelitis. 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 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.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armour Thyroid 15 milligram tablets prescribed for hypothyroidism. The Part D plan denied your request because the requested drug is not considered a Part D covered 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 information submitted at the reconsideration level. We determined that the plan is not required to cover Armour Thyroid because it is not an approved Food and Drug Administration drug. A covered Part D drug must be approved by the Food and Drug Administration. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.