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

You requested Buprenorphine Hydrochloride 8 milligram sublingual tablet three time daily for chronic back and shoulder pain with primary biliary cirrhosis. 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. 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 your physician prescribed Buprenorphine Hydrochloride 8 milligram sublingual tablet to treat chronic pain. 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 Buprenorphine Hydrochloride 8 milligram sublingual tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz XR 11 milligram tablets to treat the diagnoses of dermatomyositis and inflammatory arthritis. 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 medical record shows the requested drug is being prescribed as treatment for the enrollees condition. However, Xeljanz XR is not on the plans formulary. In addition, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vumerity capsules to treat multiple sclerosis. The Part D plan denied your request for a non-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 records submitted at the reconsideration level. The prescriber has not indicated 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 coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clindesse 2% cream prescribed for desquamative inflammatory vaginitis. 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 Clindesse for desquamative inflammatory vaginitis. 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

At issue is prescribed for Stiolto Respimat 0.032 milligram spray to treat  chronic obstructive pulmonary disease. The Part D plan denied your request for a tiering exception because there were no other brand drugs on a lower cost-sharing tier. 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.Stiolto Respimat 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

You requested Zolpidem Tartrate ER 6.25 milligram tablet prescribed for major depressive disorder and post-traumatic stress disorder. 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. The submitted documentation indicates your doctor prescribed Zolpidem Tartrate for major depressive disorder and post-traumatic stress 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 formulary exception could not be considered.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 Xifaxan 550 milligram tablets prescribed as directed for hepatic encephalopathy prophylaxis. The Part D plan denied coverage because the prior authorization criteria were not met. 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 records submitted at the reconsideration level. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records to show why the enrollee needs this medication. We did receive a prescriber statement. We did not receive the medical records requested. The prescriber statement shows the doctor prescribed Xifaxan for hepatic encephalopathy prophylaxis. The prescriber statement also indicates that Lactulose was previously tried. However, medical records were not received to support this information. 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate 500 milligram tablets prescribed twice daily for cicatricial pemphigoid. The Part D plan denied your request because the Food and Drug Administration has not approved this drug for your diagnosis. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Mycophenolate to treat your cicatricial pemphigoid. 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 Mycophenolate. A Part D drug must be prescribed for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lorazepam 0.5 milligram oral tablet prescribed three time daily for essential tremors. 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. The prescriber statement shows Lorazepam was prescribed to treat severe essential tremors. However, the Medicare approved compendia do not support the use of this drug for this condition. As such, the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.A physician reviewed your appeal and determined that the plan is not required to cover Lorazepam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dextroamphetamine-Amphetamine 30 milligram tablets prescribed two times daily for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other generic medications on a lower cost-sharing tier to treat the 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.Dextroamphetamine-Amphetamine is a generic drug on Tier 3 of the plans formulary. There are no generic drugs of the same type on the lower tiers of the plans formulary to treat the same condition. 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 Silodosin 8 milligram tablets prescribed for benign prostatic hyperplasia. 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. A supporting statement from the physician was received. The physician did not include 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 Silodosin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fetzima 24 hour sustained-action capsule 120 milligram prescribed daily for major depressive disorder. The Part D plan denied your request for a tiering exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read 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.Fetzima 24 hour sustained-action capsule 120 milligram 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 grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tymlos 80 microgram pen injector prescribed for the enrollees osteoporosis. 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. The documentation supports the drug was prescribed for the enrollees diagnosis of osteoporosis. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.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 Nurtec 75 milligram oral dissolving tablets prescribed as needed for migraine headaches. The Part D plan denied coverage because the prior authorization criteria were not met. 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 records submitted at the reconsideration level. The medical records show the doctor prescribed Nurtec to treat migraine headaches. The Medicare approved compendia do support the use of this drug for the enrollees condition. At redetermination, the prescriber indicated the enrollee experiences 15 or more headache days per month. At reconsideration, the prescriber states the enrollee experiences less than four headache days per month. The medical records submitted for review do not quantify the number of headache days per month. It could not be determined if the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Nurtec.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vumerity DR 231 milligram capsules prescribed for multiple sclerosis. 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 supporting statement did not indicate all formulary alternatives would be ineffective. 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 Vumerity DR.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amitiza 24 micrograms prescribed to treat chronic idiopathic constipation. 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. Amitiza is a non-formulary drug. We requested information as to why plans formulary alternatives are not medically appropriate to treat the enrollees condition. The prescriber did not address 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 Amitza.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol Sulfate Nebulizer Solution 2.5 milligrams/3 milliliters 0.083% prescribed for asthma. The Part D plan denied the request because requested information was not received from the prescriber. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the Albuterol Sulfate Nebulizer Solution is prescribed for asthma. Medicare records show you enrolled in Medicare Part B on May 1, 1999. This drug is eligible for payment under the Medicare Part B benefit. We determined that the plan is not required to cover Albuterol Sulfate Nebulizer Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested prior authorization coverage and a lower cost-sharing tiering exception for Tadalafil 5 milligram tablets. The Part D plan denied coverage because the prior authorization requirements were not met. Additionally, the amount of Tadalafil tablets prescribed exceeded the amount allowed by the plan. Furthermore, the tiering exception could not be granted because coverage for the medication could not be allowed. 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 medical records submitted at reconsideration indicate that the Tadalafil is being prescribed for the management of the enrollees benign prostatic hyperplasia. However, the documentation does not sufficiently address the plans prior authorization requirements for coverage of the drug. Therefore, the prior authorization guidelines for coverage of the Tadalafil have not been met. Additionally, it should be noted that the enrollee has been prescribed 90 tablets for a 30-day supply. However, the plan only allows 30 tables for a 30-day supply of Tadalafil. Furthermore, since the documentation does not support coverage of the Tadalafil, a lower cost tiering exception cannot be considered.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rytary ER 23.75-95 milligram tablets prescribed four times daily for Parkinsons disease. 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. Rytary ER 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 Rytary ER because there are no brand drugs of the same type on the lower cost sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Octreotide Acetate 200 microgram/milliliter solution prescribed for chronic lymphocytic leukemia and bilateral chylothorax. 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 Octreotide Acetate for chronic lymphocytic leukemia and bilateral chylothorax. 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 Nerlynx 40 milligram tablets prescribed for metastatic breast cancer, ER positive, HER2 negative. 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 Nerlynx for metastatic breast cancer, ER positive, HER2 negative. 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

At issue is Dupixent 300 milligram/2 milliliter injection pen prescribed for severe persistent asthma. The Part D plan denied your request because the drug was not prescribed for a medically-accepted indication, and 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 medical records support your doctor prescribed Dupixent as an add-on treatment for your severe, oral corticosteroid-dependent asthma. This is a medically accepted indication according to the Medicare accepted compendia. Your physician submitted a supporting statement. The supporting statement did not indicate all formulary alternatives would be ineffective. 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 Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acitretin 25 milligram capsules to treat the diagnosis of epidermodysplasia verruciformis. 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 prevention 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 Amphetamine-Dextroamphetamine 20 milligram ER capsules prescribed two capsules twice daily for cancer-related fatigue. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication, and a quantity limit exception could not be allowed. 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 Amphetamine-Dextroamphetamine for your metastatic brain cancer related fatigue. 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. An exception to the plan's quantity limit criteria could not be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.