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

At issue is Oxymorphone ER 15 milligram tablet prescribed twice daily for chronic pain. We received an auto-forwarded 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 Oxymorphone ER to treat your condition. 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 Oxymorphone ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is the Dexcom G6 sensor. The Part D plan denied the request because drugs that can 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 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. According to Medicare rules, Medicare Part B pays for the rental and purchase of durable medical equipment. Payment will also be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. Therefore, coverage under Part D is excluded for any drug for which payment would be available under Part B. We determined that the Medicare Part D plan is not required to cover the Dexcom G6 sensor. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent ointment to treat fibromyalgia. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. We received an auto-forwarded 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 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 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 Lidocaine 5 percent ointment because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Brovana 15 microgram/2 milliliter nebulization solution prescribed for unknown diagnosis. The Part D plan denied your request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D. We received an auto-forwarded request from the plan to reconsider the appeal.We received a 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 Brovana is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Brovana. Please submit your 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: Favorable

At issue is Travatan Z eye drops to treat open angle glaucoma. 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 plan limits the amount of Travatan Z to 2.5 milliliters per 25 days. The requested quantity of 7.5 milliliters per 90 days is within the plans allowed quantity limit. Our physician reviewer's opinion is that quantity limit criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine HCl 2 milligram sublingual tablets prescribed for chronic pain syndrome. 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 indicates your doctor prescribed Buprenorphine HCl sublingual tablets for chronic pain syndrome. 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 Osphena 60 milligram tablets prescribed daily for vaginal pain and irritation due to atrophic vaginitis. The Part D plan denied your request because the provided diagnosis 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 Osphena 60 milligram tablets to treat your vaginal pain and atrophic vaginitis. 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 Osphena because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clemastine Fumarate 2.68 milligram tablets prescribed twice daily for an enrollee with multiple sclerosis.  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 this condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Corlanor 5 milligram tablets. The Part D plan denied the request.   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.  The documentation indicates that Corlanor is being prescribed in the management of postural orthostatic tachycardia syndrome. 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. 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 Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide suspension 1 milligram/2 milliliter nebulizer solution prescribed daily for asthma. 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 Budesonide is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Budesonide. Please submit your 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 Diclofenac Epolamine 1.3% patch to treat lumbosacral ligament sprain. The Part D plan denied the request. The requested drug is not on the plans formulary. 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.We asked you to send us a prescriber statement and information regarding the enrollees condition. We also asked for medical records or other documentation to show why the medication was required. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. However, we did not receive the documentation.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. A physician reviewed the appeal and determined that the formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Levemir Flextouch 100 units per milliliter subcutaneous injection pen for the treatment of type 2 diabetes. The Part D plan denied the 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. Levemir Flextouch is not included in the plans formulary. The prescriber has not sufficiently addressed why all alternative medications included in the plans formulary to treat the noted condition would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. 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 Horizant 600 milligrams for chronic pain syndrome, cervical spondylosis with myelopathy, and cervical spine ankyloses. At initial determination and redetermination the diagnoses of chronic pain syndrome, cervical spondylosis with myelopathy, and cervical spine ankylosis were given. The Part D plan denied the request stating that the provided diagnoses are a non-medically accepted indications.  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 a diagnosis of post herpetic neuralgia was given. The medical records provided by the prescriber support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Depakote 500 and 250 milligram tablets to treat bipolar I disorder and autistic disorder. 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 Depakote for bipolar I disorder and autistic disorder. In review of the Medicare approved compendia, bipolar I disorder and autistic disorder are not medically accepted indications for Depakote as prescribed. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Depakote at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Geodon 60 milligram tablets to treat bipolar I disorder and autistic disorder. 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 Geodon for bipolar I disorder and autistic disorder. In review of the Medicare approved compendia, bipolar I disorder and autistic disorder are not medically accepted indications for Geodon. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Geodon at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Symbicort 160 microgram-4.5 microgram oral inhaler prescribed for the enrollees condition. 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.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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trulicity 4.5 milligrams/0.5 milliliter pen prescribed as directed to treat diabetes. 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. Trulicity 4.5 milligram/0.5 milliliter pen is a biologic drug on Tier 3 of the plans formulary. There are no lower tiered biologic drugs of the same type. 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 the Trulicity 4.5 milligram/0.5 milliliter pen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vascepa one gram capsule to treat hyperlipidemia.  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.Medical records from date of service 12/16/2020 were provided which substantiates the diagnosis of hyperlipidemia. The use of the requested drug to treat the provided diagnosis is an off-label use.  The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% Patch to treat polyneuropathy secondary to spinal stenosis. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.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 coverage for Hydroxychloroquine Sulfate 200 milligram tablets to treat rheumatoid arthritis. 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 Hydroxychloroquine Sulfate for rheumatoid arthritis. In review of the Medicare approved compendia, rheumatoid arthritis is a medically accepted indication for Hydroxychloroquine Sulfate. However, the medical records submitted do not support a diagnosis of rheumatoid arthritis. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Hydroxychloroquine Sulfate at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ritalin 20 milligram tablets prescribed to treat other fatigue and major depressive disorder, recurrent severe without psychotic features. The Part D plan denied your 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. We also researched Medicare regulations and Medicare approved compendia. 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. The drug is not approved by the food and drug administration to treat the diagnoses submitted. 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 Ritalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Vimpat 100 milligram tablet prescribed twice daily to treat status epilepticus. 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.Vimpat 100 milligram capsule 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.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexlizet 180-10 milligram tablet to treat hyperlipidemia. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia does not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Octreotide Acetate Solution 100 microgram/milliliter vial prescribed to treat unspecified gastrointestinal hemorrhage. The Part D plan denied your request. We received a 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 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. The drug is not approved by the food and drug administration to treat the diagnoses submitted. 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 Octreotide Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablets to treat irritable bowel syndrome with diarrhea. This case was auto-forwarded.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.Medical records have been submitted for review and do not support a required diagnosis/indication and requirements for the requested drug. As such, the documentation available 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 Xifaxan.