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

At issue is Modafinil, 200 milligram tablets prescribed twice a day for idiopathic hypersomnia with long sleep. The Part D plan denied your request because the enrollee did not have a covered condition. 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 Modafinil because idiopathic hypersomnia with long sleep is not a medically accepted indication to use this drug.The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, the requested drug does not meet the definition of a Medicare Part D drug and is therefore not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested the Tetanus, Diphtheria, and Acellular Pertussis (TDAP) injection. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received 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 records show you have a receipt and are requesting reimbursement. We asked the prescriber for information regarding the vaccine administered and medical records to corroborate the information. We did not receive the documentation requested.A physician reviewed your appeal and determined that the Tetanus, Diphtheria, and Acellular Pertussis injection cannot be considered for payment under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil, 5 milligram tablets prescribed for malignant neoplasm of the prostate. The Part D plan denied your request because the enrollee did not have a covered condition. 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 Tadalafil because malignant neoplasm of the prostate is not a medically accepted indication to use this drug.The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, the requested drug does not meet the definition of a Medicare Part D drug and is therefore not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Promethazine 6.25 milligrams/5 milliliter syrup prescribed for the enrollees cough. The Part D plan denied your request because drugs prescribed for symptomatic relief of cough and colds do not meet the definition of Part D 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 determined that the plan is not required to cover Promethazine because it was prescribed for symptomatic relief of cough. Drugs prescribed for symptomatic relief of cough and colds are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. 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

At issue is Nucynta 100 milligrams prescribed as directed for chronic pain. The Part D plan denied your request for a tiering exception. 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. The requested drug is being provided by your plan under a formulary exception. Nucynta 100 milligrams is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover Nucynta 100 milligrams because non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Farxiga 10 milligram tablets prescribed for to treat the enrollees condition. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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 records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Farxiga.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Deferasirox 250 milligram tablets prescribed for chronic iron overload in an enrollee with transfusion-dependent anemia. The Part D plan denied coverage because prior authorization criteria was not met. 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. The enrollee does satisfy the plan's coverage criteria. The prescriber states the enrollees platelet count is 52 x 10(9)/L.  Deferasirox is indicated for patients with platelet counts greater than 50 x 10(9)/L.  In the Reconsideration appeal the prescriber provided recent (2/10/2021) supporting documentation and laboratory reports documenting the platelet count and hemoglobin.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 Icosapent Ethyl 1 gram capsules prescribed as directed for mixed hyperlipidemia and elevated triglycerides and type II diabetes mellitus. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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 physician submitted supporting statements. The documentation shows the physician had prescribed Icosapent Ethyl to treat mixed hyperlipidemia with elevated triglycerides for an enrollee with type II diabetes mellitus. The Medicare approved compendium does support the use of the requested drug for the enrollees condition.However, the documentation does not show why the enrollee cannot take other drugs on the plans formulary for their condition. Specifically, the prescriber statement submitted to the plan indicates the preferred formulary drug has not been tried. The physician did not provide an explanation for why the preferred formulary drug cannot be tried. The prescriber statement submitted at reconsideration indicates the physician is requesting coverage for the preferred formulary drug. The documentation does not support an off-formulary exception for Icosapent Ethyl.A physician reviewed your appeal and determined that the plan is not required to cover this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clorazepate 3.75 milligrams tablet prescribed for anxiety and panic disorder. The Part D plan denied your request for a tiering exception for this drug at a lower cost 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.The documentation shows the enrollee was prescribed Clorazepate to treat anxiety. The following citation was referenced in a Medicare approved compendium, and supports the use of the requested drug for the enrollees condition. Clorazepate is a generic drug on Tier 4 of the plans formulary. The prescriber statement indicates that the enrollee has tried alternative drugs on the lower cost tier and have been discontinued due to moderate side effects. However, the plans formulary includes other lower tier generic alternatives of the same type to treat the enrollees condition. All generic drugs on lower tiers have not been tried. 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 Novolin 70/30 vial prescribed for type 1 diabetes. The Part D plan denied your request for a tiering exception because the drug you requested is not included on the plans formulary. 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.Novolin is a brand drug, which is not included on the plans formulary. The plan agreed to cover the drug, but the plan does not provide tiering exceptions for non-formulary drugs approved as formulary exceptions. 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 Novolin 70/30.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Novolin 70/30 injection prescribed as directed for diabetes mellitus. The Part D plan denied your request for a tiering exception. 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. The requested drug is being provided by your plan under a formulary exception. Novolin 70/30 injection is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Novolin 70/30 injection because non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 2.5 milligrams prescribed four times daily for nausea and vomiting. The Part D plan denied your request because the medication is 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. The prescriber initially provided the diagnosis of anxiety disorder, unspecified and complex regional pain syndrome.  In a letter dated February 15, 2021, the prescriber changed the diagnoses and stated you have chronic nausea since chemotherapy in 2009.  However, there are no medical records submitted to support the prescriber statement and that you are actively receiving chemotherapy. A physician reviewed your appeal and determined that the plan is not required to cover the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mirapex ER 1.5 milligram tablets prescribed for restless leg syndrome. The Part D plan denied your request because the medication is 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. The records show you prescribed Mirapex ER to treat the enrollees restless leg syndrome. 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 Mirapex ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dilantin 100 milligrams prescribed as directed for seizure disorder. The Part D plan denied your request for a tiering exception. 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. Dilantin 100 milligrams is a brand drug on Tier 4 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 Dilantin 100 milligrams because there are no brand drugs of the same type on the lower cost sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 200 milligram tablets taken 2 to 3 times a day prescribed for idiopathic hypersomnia. The Part D plan denied the request and stated the provided diagnosis is a non-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. We also researched Medicare regulations and Medicare approved compendia. The prescriber indicates the enrollee takes 2 to 3 tablets a day due to a central disorder of hypersomnolence and asked for an exception to the tablet limit as the enrollee has stabilized on 600 milligrams of Modafinil.  Medicare approved compendia do not support the use of this medication to treat  idiopathic hypersomnia. Therefore, it is ineligible for coverage under Medicare Part D.   A physician reviewed your appeal and determined that the plan is not required to cover Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omega 3-Acid 1 gram tablets prescribed for the enrollees hypercholesterolemia. 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. The documentation supports the drug was prescribed for the enrollees diagnosis of hypercholesterolemia. However, the enrollee does not satisfy the plan's coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria, as the enrollee did not have a diagnosis of hypertriglyceridemia and the enrollee did not have a triglyceride level greater than 500 milligrams/deciliter prior to initiation of therapy.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Demeclocycline 150 mg to treat syndrome of inappropriate vasopressin secretion. 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 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 your condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gralise 600 milligrams prescribed daily for chronic pain syndrome. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Gralise 600 milligrams daily to treat your chronic 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 Gralise 600 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Desvenlafaxine Succinate 50 milligram tablets were prescribed for bipolar disorder. 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 submitted documentation indicates your doctor prescribed the drug for bipolar disorder. 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 Gliostine 100 milligram capsule prescribed for Malignant neoplasm of the brain, unspecified. The Part D plan denied your request because the drug was excluded from coverage under Medicare Part D because the drug's manufacturer has not signed the Medicare Coverage Gap Discount Agreement. 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 record shows Gliostine is excluded from coverage under Medicare Part D because it is a brand drug and its manufacturer has not signed the Medicare Coverage Gap Discount Agreement. According to Medicare rules, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. The manufacturer, NextSource biotechnology, did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, we determined that the plan is not required to cover the Gliostine. 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 Nexletol 180 milligram tablets prescribed for coronary artery disease. 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 physician submitted a supporting statement. The documentation indicates the physician had prescribed Nexletol to treat your coronary artery disease. 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 physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Nexletol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gabapentin 600 milligrams prescribed as directed for cervical spinal stenosis and chronic pain. The Part D plan denied your request for a quantity limit 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 medical records show your doctor prescribed Gabapentin to treat your condition. However, quantities that are higher than the Food and Drug Administration approved dosing regimen cannot be covered unless the requested dose is supported by the Medicare compendia. An exception to the quantity limit criteria was not met. Therefore, the plan is not required to cover the requested quantity of Gabapentin.A physician reviewed your appeal and determined that the plan is not required to cover the Gabapentin as the drug exceeds the number of doses that may be dispensed during a specific period of time.