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

You requested Dronabinol 2.5 milligrams prescribed twice daily for nausea with vomiting, unspecified due to complex regional pain syndrome. 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. We also researched Medicare systems and reviewed the enrollment data available.The record shows you were prescribed Dronabinol 2.5 milligrams twice daily for nausea with vomiting, unspecified due to complex pain syndrome. 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 Dronabinol 2.5 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz 10 milligrams prescribed twice daily for Crohns disease. 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 Xeljanz 10 milligrams twice daily to treat your Crohns disease. 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 Xeljanz 10 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 10 milligrams prescribed daily for type 2 diabetes. The Part D Plan denied your request for a tiering exception because there is not an alternative brand name drug for the enrollees condition in a lower cost-sharing tier. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read 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.Jardicance 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Dilantin 100 milligrams prescribed daily for seizures. The Part D plan denied your request for a tiering exception because Dilantin is a brand name Tier 4 drug and the lower cost-sharing tiers only contain generic alternative drugs. 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 record shows Dilantin is being prescribed for seizures. The Medicare approved compendium supports the use of the requested drug for your condition. The plan shows Dilantin is a brand name Tier 4 drug. There are no brand name drugs of the same type on the lower cost sharing levels. Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested lidocaine 5% patch prescribed for neuropathic pain in neck and shoulders. The Part D plan denied your request because the 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. We were unable to obtain medical records to support the medical necessity for this medication. The prescribers statement supports your physician prescribed the lidocaine 5% patch to treat your neuropathic pain in your neck and shoulders. 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 lidocaine 5% patch. This medication has not been medically approved for your diagnosis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mesalamine 1,000 milligrams suppository prescribed daily for ulcerative colitis. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited reconsideration request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The record shows that your doctor prescribed Mesalamine 1,000 milligrams suppositories to treat your ulcerative colitis. The Medicare approved compendium supports the use of this drug to treat your condition. However, your doctor submitted a prescribers statement that shows no other drugs have been tried to treat your condition. Your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Mesalamine 1,000 milligrams suppositories because your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Breo ellipta 200 micrograms prescribed daily for asthma. The Part D Plan denied your request because there are no lower tier brand drugs available on the plans formulary to treat the enrollees condition. 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 record shows you were prescribed Breo ellipta 200 micrograms daily for asthma. Breo ellipta 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 Breo Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Letairis, 5 milligram tablets prescribed for secondary pulmonary artery hypertension. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your doctor submitted a supporting statement and medical records. The medical records show that Letairis was prescribed to treat your secondary pulmonary artery hypertension. The 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. Your medical records do show that you have tried the drug, Tadalafil, which did not work. However, there are other drugs listed on your plans formulary to treat your condition that have not been tried.A physician reviewed your appeal and determined that the plan is not required to cover the Letairis as an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Mycophenolate Mofetil 1000 milligrams for neurosarcoidosis. 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. We also researched Medicare systems and reviewed the enrollment data available.The record shows you were prescribed Mycophenolate Mofetil for neurosarcoidosis. The Medicare approved compendia does not support the use of the requested drug to treat neurosarcoidosis. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Mycophenolate Mofetil at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% ointment prescribed daily for chronic knee pain. The Part D plan denied your request because the enrollees diagnosis did not support 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 medical records show Lidocaine 5% ointment was prescribed for the enrollees chronic knee pain due to osteoarthritis. However, the Medicare approved compendia do not support the use of this drug for this condition. The compendia indicate this ointment is only intended for local anesthetic for mucous membrane of the oropharynx; use in laser/cosmetic surgeries; itching, insect bites, pain, soreness, minor burns (including sunburns), cuts, and abrasions of the skin; discomfort due to conditions of the skin and mucous membranes; local management of skin wounds, including pressure ulcers, venous stasis ulcers, first- and second-degree burns, and superficial wounds and scrapes.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aspirin 25 mg/extended-release dipyridamole 200 mg prescribed as directed for the prevention of recurrent stroke. The Part D plan denied coverage because the step therapy requirements were not met. Specifically, the documentation did not explain why Clopidogrel would not work for this enrollee. 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 medical records show the doctor prescribed Aspirin/extended-release dipyridamole to prevent recurrent stroke. The Medicare approved compendia do support the use of this drug for this condition.The plan requires prior treatment with Clopidogrel 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 Aspirin/extended-release dipyridamole.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Progesterone 4% gel, 1 application vaginally every other day, for menopausal hormone therapy. The Part D plan denied your request because the drug was ordered for 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 medical records show your doctor prescribed Progesterone 4% gel for hormone replacement therapy due to menopause. 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 Progesterone 4% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Azathioprine 50 mg tablet, prescribed twice daily for sarcoidosis. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Azathioprine to treat your sarcoidosis. Your physician indicated that low-dose prednisone therapy was not adequate to control and prevent progression of the disease. 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 Azathioprine for your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Piqray 150 milligram tablets prescribed at a dosage of 300 milligrams once daily for breast cancer. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The medical records show the doctor prescribed Piqray to treat HER2 positive metastatic breast cancer. 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 Piqray.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 24 to 26 milligrams prescribed daily for chronic heart failure. The Part D Plan denied your request for a tiering exception. 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.Entresto is a brand drug on Tier 3 of the Plans formulary. The prescriber statement shows the enrollee was being treated for congestive heart failure with an ejection fraction of 40%. The enrollee also has multiple risk factors that increase their risk of having future cardiovascular events. 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 the enrollee's condition.A physician reviewed your appeal and determined that the Plan is not required to cover Entresto.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cialis 5 milligrams prescribed as directed for disorder of urinary system. 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 Cialis 5 milligrams to treat your disorder of urinary system. 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 Cialis 5 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cresemba 186 milligrams prescribed for a diagnosis of antifungal protection/prevention of invasive aspergillosis. 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 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.Your medical records show your doctor prescribed Cresemba for your diagnosis of antifungal protection/prevention of invasive aspergillosis. A review of the Medicare compendia does not reveal a medically accepted indication for use of this drug for your condition.  Your diagnosis does not indicate you have invasive aspergillosis.A physician reviewed your appeal and determined that the plan is not required to cover Cresemba.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Butrans 20 micrograms per hour prescribed daily for spinal stenosis. The Part D plan denied the 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. We also researched Medicare systems and reviewed the enrollment data available.The record shows you were prescribed Butrans 20 micrograms per hour daily for spinal stenosis. However, the Medicare approved compendia do not support the use of this drug for your condition. The request for a tiering exception was not reviewed. We cannot consider a tiering exception for a drug that is not eligible for Part D coverage. 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 Butrans 20 micrograms per hour because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Wellbutrin XL 300 milligram tablet prescribed for recurrent depression. The Part D plan denied your request to cover this drug at a lower tier cost. The plan indicated this is a non-formulary drug and cannot be provided at a lower tier cost. 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 Wellbutrin XL was prescribed to treat recurrent depression.   Wellbutrin XL is a non-formulary approved drug and is not eligible for a tiering exception.  A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception for the Wellbutrin XL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Saxenda injection prescribed for the treatment of weight gain. The Part D plan denied the request because the plan indicated this drug is excluded from Part D. 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. We determined that the plan is not required to cover Saxenda because it was used to treat severe obesity. Drugs to treat weight gain (promote weight loss) are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dupixent 300 mg/2ml prescribed daily for allergic contact dermatitis, unspecified. 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 Dupixent to treat your allergic contact dermatitis. However, the Medicare approved compendia do not support the use of this drug for allergic contact dermatitis.  A physician reviewed your appeal and determined that the plan is not required to cover Dupixent. The drug was not prescribed for a medically accepted indication. 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

You requested Effexor XR, 150 milligram capsules for a 90-day supply, being prescribed for anxiety disorder. The Part D plan denied your request for a 90-day supply because Effexor XR is a specialty drug limited to a 30-day supply. Therefore, the plan approved the Effexor XR for a 30-day supply only. 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. A physician reviewed your appeal and determined that the plan is not required to cover the 90-day supply of Effexor XR, as the drug exceeds the number of doses that may be dispensed during a specific period of time.Your medical records show your doctor prescribed Effexor XR to treat your anxiety disorder. Effexor XR is listed in the plans formulary as a specialty drug. The plan only allows a 30-day supply at a time. An exception to the quantity limit criteria was not met. Therefore, the plan is not required to cover a 90-day supply of Effexor XR.