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

At issue is Amphetamine-Dextroamphetamine extended release 10 milligram capsule to treat a traumatic brain injury.  The Part D Plan denied the request stating that the provided diagnosis is a non-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 diagnosis is an off-label use.  The Medicare approved compendia does 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: Favorable

At issue is Venclexta 100 milligram tablets to treat myelodysplastic 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 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 FDA has granted orphan drug designation for Venclexta for the treatment of myelodysplastic syndromes.The enrollee does not satisfy the Plan's coverage criteria.  The Plans prior authorization coverage criteria is for the diagnosis of 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

At issue is Sunosi 150 milligrams prescribed once daily for sleep apnea. 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. We also researched Medicare systems and reviewed the enrollment data available.The prescriber submitted a sleep study test that supports the diagnosis of obstructive sleep apnea and the prescriber stated the enrollee tried Wellbutrin and Adderall with no improvement. However, the documentation continues to not support that an adequate trial and failure occurred with the medication Modafinil and Armodafinil as required in the prior authorization rules.The plan requires an adequate trial and failure of the medications Modafinil and Armodafinil before coverage of Sunosi can be approved. 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 Sunosi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Doptelet 20 milligrams prescribed as directed for immune thrombocytopenic purpura.   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

At issue is Deferasirox 360 milligrams prescribed three times a day for myelodysplastic syndrome. The Part D plan denied your request because the documentation did not support an off-formulary exception since not all preferred drugs were previously tried. 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 physician submitted a supporting statement. The prescriber statement shows the physician had prescribed Deferasirox to treat myelodysplastic syndrome with hemochromatosis. However, the records do not show why preferred alternatives on the plans formulary for the same condition have not been tried. Specifically, the documentation does not show that the enrollee has tried other formulary alternatives, or why the enrollee cannot take them.A physician reviewed your appeal and determined that the plan is not required to grant a non-formulary exception for the Deferasirox.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 420 milligrams per 3.5 milliliter subcutaneous prescribed monthly for mixed hyperlipidemia. 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 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

At issue is Tramadol 37.5 milligram/Acetaminophen 325 milligrams tablets prescribed as directed for chronic pain related to fibromyalgia. The Part D plan denied coverage because a prescriber statement verifying the need for greater than a seven-day supply of the drug was not submitted. 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 documentation shows the provider prescribed Tramadol/Acetaminophen for chronic pain. The Medicare approved compendia do not support the use of this drug for chronic pain. Since the drug was not prescribed for a medically accepted indication, the need for greater than a seven-day supply cannot be established.A physician reviewed your appeal and determined that the plan is not required to cover Tramadol/Acetaminophen.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac 1.5 % topical solution prescribed as directed for rheumatoid arthritis. 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 Diclofenac 1.5 % topical solution for rheumatoid arthritis. 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 Diclofenac because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate 20 milligrams prescribed twice daily for multiple sclerosis related fatigue. 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. The medical records shows Methylphenidate 20 milligrams twice daily was prescribed to treat multiple sclerosis related fatigue. 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 Methylphenidate 20 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Methylphenidate HCL 20 milligrams ER tablet prescribed daily for fatigue due to multiple sclerosis. 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 Methylphenidate HCL for fatigue due to multiple sclerosis. In review of the Medicare approved compendia, fatigue due to multiple sclerosis is not a medically accepted indication for Methylphenidate HCL. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Methylphenidate HCL at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 500 milligram tablets prescribed for necrotizing myopathy. The Part D plan denied your request because this drug is not medically accepted for this condition. 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 use of this drug 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 Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azopt 1% eye drops prescribed one drop, twice daily in each eye for open angle glaucoma. The Part D plan denied your request for prior authorization 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 has prescribed Azopt to treat your glaucoma. Medicare approved compendia support the use of the requested drug for your condition. However, the records do not show why you cannot take other drugs on your plans formulary for your condition. Additional medical records were requested to show what alternative medications were tried and failed. We did not receive the documentation requested.A physician reviewed your appeal and determined that the plan is not required to cover Azopt. The documentation does not support you have tried all other alternatives listed within your plans formulary to treat your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Tegretol XR 100 milligram tablets prescribed daily for neuropathic pain due to femoral neuropathy. The Part D plan denied your request because the off formulary rules were not met. 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 Tegretol XR for neuropathic pain due to femoral neuropathy. This is not a listed drug on your formulary. In review of the Medicare approved compendia, neuropathic pain due to femoral neuropathy is not a medically accepted indication for Tegretol XR. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Tegretol XR at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested ColciGel prescribed for acute gout attacks. The Part D plan denied your request because the Food and Drug Administration has not approved this drug for your diagnosis. 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 ColciGel to treat your gout. However, the Medicare approved compendia 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 ColciGel. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Creon 24,000 unit extended release capsules prescribed daily for exocrine pancreatic insufficiency. The Part D plan denied your request for a tiering. We received an expedited 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. Creon is a brand drug that is not on the plans formulary. Medicare has already granted a formulary exception for the drug. A tiering exception cannot be allowed for a drug that is not on the plans formulary. Therefore, this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 10 milligram tablets prescribed daily for uncontrolled dibaetes. 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.Jardiance is a brand drug on Tier 3 of the plans formulary. The prescriber statement shows you are being treated for uncontrolled diabetes. You doctor stated you have a glycated hemoglobin of 7.8% despite being on the maximum dose of Metformin, Januvia, and Glipizide. However, 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. There are no lower tiered brand drugs of the same type to treat your condition.A physician reviewed your appeal and determined that the plan is not required to cover Jardiance.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Androgel 1.62% prescribed daily for Late-onset (age-related) hypogonadism in males. The Part D plan denied your request 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. Your medical records show your doctor prescribed Testosterone to Late-onset (age-related) hypogonadism, as indicated on the Prior Authorization documentation. The Medicare approved compendia do not support the use of this drug for your condition. There is no medically accepted indication in the compendia. A physician reviewed your appeal and determined that the plan is not required to cover Androgel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 25 milligram/2.5 gram (1%) transdermal gel used daily to treat your unspecified low testosterone.  The Part D plan denied the request stating that the provided diagnosis 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 use of the requested drug to treat the provided diagnosis is not a medically accepted indication. At reconsideration, the physician stated you have primary hypogonadism or testicular hypo-function but there were no medical records submitted to support this new diagnosis. The documentation does not support you have a covered diagnosis.  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 Testosterone. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuedexta 20-10 milligram capsules prescribed as directed for pseudobulbar affect. 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. Nuedexta is a brand drug on Tier 5, also known as the specialty tier, of the plans formulary. If a plan maintains a specialty tier, the plan may design its exception process so that drugs placed in the specialty tier are not eligible for a tiering exception. The record indicates the plan has chosen to exclude the specialty tier from the tiering exception process. 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 Nuedexta. A tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% Cream. 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. Drugs prescribed that are available over the counter are excluded from coverage under Medicare Part D. Therefore, we determined that the plan is not required to cover the Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcipotriene 0.005% cream prescribed twice daily for Grovers Disease. The Part D plan denied your request because the requested 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 prescriber statement shows Calcipotriene cream was prescribed to treat Grovers Disease or Transient Acantholytic Dermatosis. The enrollee has tried Triamcinolone Acetonide, Halobetasol, and Clobetasol with no relief. However, the Medicare approved compendia do not support the use of this drug for your condition. The medical record does not include a medically accepted indication for the drug at issue. A physician reviewed your appeal and determined that the plan is not required to cover Calcipotriene 0.005% cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligam capsules prescribed FREQUENCY for the treatment of non-24 hour sleep wake cycle. The Part D plan denied coverage because prior authorization criteria for the drug was not met. We received a request 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The medical records show Hetlioz 20 milligam capsules are being prescribed to treat the enrollees condition. The Medicare approved compendia do support the use of this drug for the enrollees condition. The medical record also includes a completed prior authorization form. The form shows the enrollee has a diagnosis of non-24 hour sleep wake cycle and has a circadian rhythm longer than 24 hours that has been confirmed by daily sleep logs and actigraphy for at least 15 days. However, the diagnosis and confirmation of the circadian rhythm is not supported by clinic documentation of November 6, 2020. Therefore, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz 20 milligam capsules, because the prior authorization requirements were not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Symbicort 160/4.5 microgram aerosol inhaler prescribed as two puffs twice a day. The Part D plan denied your request for a tiering exception because there were no brand drugs of the same type on the lower cost sharing tiers. 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. Symbicort 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 grant your request for a tiering exception.