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

You requested Durezol 0.05% emulsion prescribed to instill 1 drop into both eyes twice a day to treat cystoid macular edema. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows your doctor prescribed Durezol 0.05% emulsion to treat cystoid macular edema of both eyes. 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 Durezol 0.05% emulsion.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Motegrity 2 milligram tablets prescribed to treat constipation. The Part D plan denied your request.We received the case to perform 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.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you.A physician reviewed your appeal and determined that the plan is not required to cover Motegrity 2 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cinacalcet HCL 30 milligram tablet prescribed daily for the treatment of end stage renal disease. The Part D plan denied your request.We received the case to perform 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. According to Medicare rules, the requested drug cannot be approved for separate payment under Part D when it's for treatment on a patient who is receiving dialysis. Medicare records show the enrollee is actively receiving dialysis. Therefore, the Cinacalcet HCL must be billed by the renal dialysis facility. We determined that the plan is not required to cover the Cinacalcet HCL. Please submit your request for this drug through the dialysis provider.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550-milligram tablet. At initial determination and redetermination the diagnosis of irritable bowel syndrome with constipation was given. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication(s).  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.At reconsideration diagnoses of hepatocellular carcinoma and hepatic encephalopathy were given. In the original appeal the prescriber was asked if the enrollee had hepatic encephalopathy.  The prescriber answered, 'No.'   The Reconsideration appeal asked for, 'Relevant Medical Records.'   No medical records were provided by the prescriber to support the change in diagnoses.  It could not be determined whether the requested drug was being prescribed for medically accepted indications. 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 Flector 1.3% patch prescribed to treat pain due to partial non-traumatic amputation of the left foot. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows your doctor prescribed Flector 1.3% patch to treat pain due to partial non-traumatic amputation of the left foot. 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 Flector 1.3% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo 2 milligram tablet prescribed daily for mixed hyperlipidemia. The Part D plan denied your request.We received the case to perform 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In the Reconsideration appeal letter dated May 28, 2021, the prescriber stated that the enrollee is , 'intolerant to statins.'  Yet, the requested drug, Livalo,' is a statin.  A physician reviewed your appeal and determined that the plan is not required to cover Livalo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Gabapentin 300 milligram tablets. We received the case to perform 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 Gabapentin has been prescribed for neuropathic pain in both legs due to lumbar spinal stenosis with neurogenic claudication. 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 drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the Gabapentin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methocarbamol 500 milligram oral tablet, used as needed for non-acute pain. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Methocarbamol to treat an unspecified neck fracture. 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, as ordered, is not being used for a medically accepted indication. 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 methocarbamol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azathioprine 51-milligram tablet to treat autoimmune necrotizing myopathy. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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.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 prior authorization for Methotrexate Sodium 2.5 milligram tablets prescribed as directed for systemic sclerosis. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Methotrexate Sodium to treat your systemic sclerosis. 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.A physician reviewed your appeal and determined that the plan is not required to cover Methotrexate Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Divigel 1 milligram gel packet prescribed daily for gender dysphoria. The Part D plan denied your request.We received the case to perform 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Divigel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epogen 4,000 units/mL, 2 vials per week prescribed for anemia due to chronic kidney disease (not on dialysis). The Part D plan denied your request.We received the case to perform 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 asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review. Your medical records show your doctor prescribed Epogen to treat your anemia due to chronic kidney disease. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Epogen. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 50 milligram tablets. The Part D plan denied your request for a tiering exception.We received the case to perform 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.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 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

At issue is a request for coverage of Xifaxan 550 milligram tablets. The Part D plan denied the request for coverage because the plans prior authorization requirements were not met.We received the case to perform 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 prescriber statement submitted with the reconsideration file states that the enrollee has epilepsy with elevated blood ammonia levels and Xifaxan has been prescribed to reduce the enrollees blood ammonia levels. In the appeal the prescriber was asked, 'Is the requested drug being prescribed to reduce the risk of overt hepatic encephalopathy?'  The prescriber answered, 'No.'  As well, the prescriber in the appeal stated that the drug was being used to treat irritable bowel syndrome with diarrhea.  However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition (elevated blood ammonia levels). Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D.   No medical records were submitted with this appeal.  Since the drug is not eligible for coverage under Part D, the plans prior authorization requirements are not applicable to this review. A physician reviewed the appeal and determined that the plan is not required to cover the Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcitriol 0.25 microgram prescribed for hypocalcemia secondary to end stage renal disease. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. We spoke to your physician and he confirmed the diagnosis. You are receiving dialysis for your end stage renal disease and require the Calcitriol for your hypocalcemia. However, this drug may be eligible for coverage under Medicare Part B. We determined that the plan is not required to cover Calcitriol. Drugs that are eligible for coverage under the Part B end stage renal disease payment bundle are not covered by Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Adderall XR 20 milligram oral capsule prescribed for fatigue related to multiple sclerosis. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Adderall XR to treat your chronic fatigue related to multiple sclerosis. 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, as ordered, is not being used for a medically accepted indication. 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 Adderall XR.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Estradiol micronized powder prescribed as directed. The Part D plan denied your request.We received the case to perform 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 noted that you requested coverage for a compounded drug product. Therefore, we reviewed each ingredient individually. Bulk powders (that is, active pharmaceutical ingredients for compounding) do not satisfy the definition of a Part D drug and are not covered by Part D. Therefore, the Estradiol micronized powder ingredient is not eligible for Part D coverage. The plan is not required to provide reimbursement for it. This decision does not address the medical necessity of this drug. It only means that payment cannot be made under the Medicare Part D benefit.We determined that the plan is not required to cover the Estradiol micronized powder.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Glycerin liquid prescribed as directed. The Part D plan denied your request.We received the case to perform 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 noted that you requested coverage for a compounded drug product. Therefore, we reviewed each ingredient individually. Medicare Part D does not cover non-prescription drugs. We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the drug is a non-prescription or over-the-counter (OTC) drug. Therefore, the Glycerin liquid ingredient is not eligible for Part D coverage. The plan is not required to provide coverage for it. This decision does not address the medical necessity of this drug. It only means that payment cannot be made under the Medicare Part D benefit.We determined that the plan is not required to cover the Glycerin liquid.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested PFCB cream prescribed as directed. The Part D plan denied your request.We received the case to perform 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 noted that you requested coverage for a compounded drug product. Therefore, we reviewed each ingredient individually. Medicare Part D does not cover non-prescription drugs. We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the drug is a non-prescription or over-the-counter (OTC) drug. Therefore, the PFCB cream base ingredient is not eligible for Part D coverage. The plan is not required to provide coverage for it. This decision does not address the medical necessity of this drug. It only means that payment cannot be made under the Medicare Part D benefit.We determined that the plan is not required to cover the PFCB cream.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lenvima 14 milligram capsules prescribed for metastatic renal cell carcinoma. The Part D plan denied your 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 did not include medical records or a supporting statement for this drug. A request for information was sent to your physician. Medical records and a supporting statement were received. However, the medical records do not support your physician ordered the drug at issue for a medically accepted indication. 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 Carisoprodol 350 milligram tablet prescribed for musculoskeletal pain. 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.In order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, medical records supporting that medically accepted indication are required. These records were requested from the prescriber, and we did not receive information that could answer these medical necessity issues.  The requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Omnipod dash 5-pack pods prescribed for type 1 diabetes. The Part D plan denied your request.We received the case to perform 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 plan denied your request for reimbursement because National Drug Code had been discontinued. A valid National Drug Code was not present with the Food and Drug Administration. The numbers were invalid and therefore, not eligible for coverage or under Medicare Part D.  We determined the plan is not required to cover and provide reimbursement for Omnipod dash.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hyoscyamine Sulfate 0.125 mg sublingual tablets prescribed as directed. The Part D plan denied your request. We received the case to perform 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 physician prescribed Hyoscyamine Sulfate. Hyoscyamine Sulfate has not been approved by the Food and Drug Administration. Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.We  determined that the plan is not required to cover Hyoscyamine Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methocarbamol 500 milligram tablet prescribed for chronic use to treat pain due to spinal stenosis, lumbar region with neurogenic claudication.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Methocarbamol 500 milligram tablet for chronic use to treat pain due to spinal stenosis, lumbar region, with neurogenic claudication. However, Medicare approved compendia do not support this drug for chronic use.  A physician reviewed your appeal and determined that the plan is not required to cover Methocarbamol.