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

You requested Acetylcysteine 10% solution prescribed orally for chronic constipation secondary to cystic fibrosis. The Part D plan denied your request because the medication is 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 records show you prescribed Acetylcysteine 10% solution taken orally to treat the enrollees chronic constipation. 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 Acetylcysteine 10% solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Insulin Aspart 100 u/ml pen to treat Type 2 diabetes mellitus with hyperglycemia. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber has not indicated why all alternatives required by the plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the plans 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 coverage for Pentasa 500 milligrams prescribed two capsules four times daily for  Crohn's disease, unspecified, without complication. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. 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 record shows you were prescribed Pentasa for Crohns disease, unspecified, without complication. In review of the Medicare approved compendium, Crohns disease, unspecified, without complication is not a medically accepted indication for Pentasa. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Pentasa at issue.
Appeal type: Prescription Drug
Decision: Favorable

You requested Tibsovo 250 milligram tablets prescribed twice daily for C22.1, Intrahepatic bile duct carcinoma. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an auto-forwarded reconsideration request from the plan. 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 the requested drug for C 22.1, intrahepatic bile duct carcinoma. The Medicare approved compendia  National Comprehensive Cancer Network, Inc. (NCCN) supports the use of the requested drug to treat C22.1, Intrahepatic bile duct carcinoma and states:  Subsequent treatment as a single agent (useful in certain circumstances) for progression on or after systemic treatment for unresectable or metastatic disease with an isocitrate dehydrogenase-1 (IDH1) mutation.  The enrollee does not satisfy the Plan's coverage criteria.  The enrollee does not have acute myeloid leukemia.  Therefore, an exception to the Plans coverage criteria is medically necessary. A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested testosterone cypionate, 200 milligrams/milliliter solution prescribed intramuscular, every two weeks for low testosterone level in male, metabolic disorder, and male erectile dysfunction did not meet the requirements 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 testosterone cypionate to treat your low testosterone level in male, metabolic disorder, and male erectile dysfunction. 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 testosterone cypionate because you do not have a medically accepted indication per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gralise 600 milligrams prescribed daily for idiopathic progressive peripheral neuropathy. 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 Gralise 600 milligrams daily to treat your idiopathic progressive peripheral neuropathy. 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 Gralise 600 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide 3 milligram capsules two times daily for the treatment of graft-versus-host disease. The Part D plan denied the request because treatment of graft-versus-host disease is not a Food and Drug Administration approved diagnosis for the use of this medication. 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 medical records show Budesonide the treatment of graft-versus-host disease. The Medicare approved compendia do not contain any citations to support the use of the requested drug for the noted condition. Therefore the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. 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.A physician reviewed your appeal and determined that the plan is not required to cover the Budesonide because it not a medically accepted indication to use this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuedexta 20-10 milligrams prescribed twice daily for pseudobulbar affect. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Nuedexta 20-10 milligrams twice daily to treat your pseudobulbar affect. The Medicare approved compendia support the use of this drug for your condition. However, the plans prior authorization criteria for this drug have not been satisfied. Therefore, the drug cannot be considered for payment under by the plan.A physician reviewed your appeal and determined that the plan is not required to cover Nuedexta 20-10 milligrams because the plan requires prior authorization before covering some prescription drugs.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lyrica 150 milligrams capsules prescribed three time daily for fibromyalgia pain. You asked the Part D plan to provide a tiering 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. We also researched Medicare systems and reviewed the enrollment data available.The records show Lyrica is being prescribed for fibromyalgia pain. The Medicare approved compendia support the use of the requested drug for your condition. The plan shows Lyrica is a brand name Tier 3 drug. Your doctor submitted a prescriber statement indicating that you tried Pregabalin. This drug did not control your condition. However, the plan formulary includes other drugs that could be used to treat your condition. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ipratropium/Albuterol 0.5-3/3 ampule nebulizer solution prescribed as directed for chronic obstructive pulmonary disease. 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 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 Ipratropium/Albuterol 0.5-3/3 ampule nebulizer solution to treat your chronic obstructive pulmonary disease. The Medicare approved Compendia support the use of this drug for your condition. However, we determined that the drug is not eligible for Part D coverage. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. Therefore, the drug cannot be considered for payment under the Part D benefit.   A physician reviewed your appeal and determined that the plan is not required to cover Ipratropium/Albuterol 0.5-3/3 ampule nebulizer solution because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit.You may wish to submit a request for Ipratropium/Albuterol 0.5-3/3 ampule nebulizer solution to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Humira 40 milligrams injection pen prescribed as directed for sarcoidosis. The Part D plan denied the 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. The record shows you were prescribed Humira 40 milligrams injection pen as directed for sarcoidosis. 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 Humira injection pen because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rhopressa 0.2 percent eye solution prescribed as directed for open angle glaucoma. The Part D plan denied your 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 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. Rhopressa 0.2 percent eye solution is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Rhopressa 0.2 percent eye solution because there are no brand drugs of the same type on the lower cost sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lupron Depot 22.5 milligrams  prescribed every three months for prostate cancer. 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 auto-forwarded request from the plan to reconsider the appeal.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 Lupron Depot is being prescribed to the enrollee for the treatment of prostate cancer. The documentation provided shows the drug was initially supplied by the prescriber and administered to the enrollee in the prescribers office. According to Medicare rules, Part B pays for services and supplies from physician and/or office stock supply, and should be billed as part of a physician service. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. No additional documentation was requested from the prescriber. We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Lupron Depot. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Mybetriq ER 50 milligrams to treat urinary incontinence. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Mybetriq ER 50 milligrams is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug 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 Orphenadrine Citrate 100 milligram tablets prescribed twice daily for primary osteoarthritis of both knees. 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. Your medical records show your doctor prescribed the requested drug to treat primary osteoarthritis of both knees. 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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

 At issue is Myrbetriq ER 25 milligram tablets prescribed to treat neurogenic bladder related to progressive multiple sclerosis. The Part D plan denied your request for a tiering exception because the drug is covered at the cost-sharing tier listed in the current drug guide and there is no brand name drug for this condition in a lower cost-sharing tier. 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 rules and the plans formulary.Myrbetriq ER is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower Tiers of the plans formulary to treat the same condition. 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 Myrbetriq ER at a lower cost-sharing amount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gamunex-C, injection, 5 milligrams per 50 milliters prescribed every five weeks for myasthenia gravis. The Part D plan denied coverage because Gamunex-C prior authorization guideline criteria was not met. We received a request to reconsider this appeal.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 documentation received includes a completed prior authorization form. The form indicates there must be evidence of myasthenia gravis exacerbation with specified symptoms in the last month. The prescriber statement indicates the Gamunex-C is not for myasthenia exacerbation, but for maintenance treatment. The medical records do not show the enrollee has had a recent exacerbation. Additionally, the Medicare approved compendia do not support the use of this drug for myasthenia gravis. Therefore, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover Gamunex-C, injection, 5 milligrams per 50 milliters, because it was not prescribed for a medically accepted indicated and prior authorization requirements were not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 50 microgram tablet prescribed daily for hypothyroidism. The Part D Plan denied your request for a tiering exception because the generic does not work for you. 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. Synthroid is a brand drug on Tier 4 of the plans formulary. The prescriber statement shows the generic brand caused fluctuating thyroid stimulating hormone levels. 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. There is no brand drug on a lower eligible tier that is used to treat your condition. Therefore, your plan is not required to offer you a lower cost share.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xelpros Emulsion 0.0005% prescribed for open angle glaucoma. The Part D plan denied your request for a tiering exception because the drug had already been approved for a non-formulary exception and therefore, a tiering exception could not be made. 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 law and the plans rules.The documentation in the record shows that Xelpros is covered for the enrollee through a formulary exception. Medicare law and plan rules do not allow tiering exceptions for non-formulary drugs being covered through a formulary exception. 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 Xelpros.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amitiza, 80-microgram capsule prescribed twice daily for constipation. The Part D plan denied your request because your diagnosis of constipation is not a Food and Drug Administration supported 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 Amitiza to treat your constipation. 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 Amitiza because you do not have a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Travatan Z eye drops. The Part D plan denied your request for a tiering exception because the drug you requested is not included on your plans formulary.  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 were prescribed Travatan Z eye drops. Since the drug isnt on the plans formulary it is not eligible for a tiering exception. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Travatan Z eye drops as an tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5 milligrams to be given twice daily for postural orthostatic tachycardia syndrome. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level.Corlanor is being requested to treat postural orthostatic tachycardia syndrome. The Medicare approved compendia do 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 Corlanor.