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

At issue is Northera 100 mg capsules.   At initial determination and redetermination the diagnosis of postural orthostatic hypotension was given.  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. At reconsideration a diagnosis of pure autonomic failure was given. The record shows you were prescribed Northera for postural orthostatic hypotension. In review of the Medicare approved compendia, postural orthostatic hypotension is not a medically accepted indication for Northera. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Northera at issue.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 a Freestyle Libre 14 day sensor to treat diabetes mellitus.  The Part D Plan denied the request because Medicare Part B covers medical supplies that are not directly related to the delivery of insulin to the body. 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. Based on the information provided, we determined the Freestyle Libre 14 day sensor would be eligible for coverage under Part B.   A physician reviewed your appeal and determined that the requested Freestyle Libre 14 day sensor is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested promethazine hydrochloride, 50-milligram tablet prescribed daily for nausea and vomiting, unspecified. The Part D plan denied your request because the use of this drug for your condition is not a medically accepted indication per Medicare rules. Additionally, for the diagnosis if nausea and vomiting you must have previously tried and failed therapy with a prescription strength oral antiemetic. 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 promethazine hydrochloride to treat your nausea and vomiting, unspecified. However, the Medicare approved compendia do not support the use of this drug for your condition. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, would likely cause harm or not be as effective for the enrollee as the requested drug. A physician reviewed your appeal and determined that the plan is not required to cover promethazine hydrochloride because you do not have a medically accepted indication per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 20 milligrams, 1 tablet as needed prescribed daily for erectile dysfunction. The Part D plan denied your request because Medicare does not cover drugs for sexual dysfunction. 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 Tadalafil for erectile dysfunction. In this instance, Medicare does not cover drugs for sexual dysfunction.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Procrit Solution 4,000 units/milliliters prescribed as directed for anemia related to chronic kidney disease. 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. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show you were prescribed Procrit Solution 4,000 units/milliliters for your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided does not show the coverage criteria has been met. 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 Procrit Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Venetoclax 100 milligram tablets prescribed as directed for chronic myelomonocytic leukemia. 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 enrollee has chronic myelomonocytic leukemia. The Medicare approved compendia do not support the use of Venetoclax for chronic myelomonocytic leukemia. A physician reviewed your appeal and determined that the plan is not required to cover Venetoclax.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hizentra 10/50 milliliters to treat Immune-mediated acute inflammatory polyneuropathy with autonomic dysfunction, costochondritis, and polyclonal IgA gammopathy.  The Part D plan denied the request stating that the provided diagnosis is 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 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 the enrollees condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Topamax 100 milligram tablet for the prophylaxis of migraine headache.  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 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.This drug is being provided by your plan under a formulary exception. It 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 2.5 milligram capsules prescribed as directed for intractable vomiting, weight loss, and loss of appetite. The Part D plan denied your request because the drug might be covered by Medicare Part B. The Part D plan also denied your request because the drug was not prescribed for a medically accepted indication. In addition, the Part D plan denied your request because the drug requires prior authorization. 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 documentation shows the doctor prescribed Dronabinol to treat intractable vomiting, weight loss, and loss of appetite. The documentation does not show that the medication was prescribed to treat nausea and vomiting within 48 hours after chemotherapy. Therefore, the drug would not be covered under Medicare Part B, and is eligible for consideration of Medicare Part D coverage. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. Since the drug was not prescribed for a medically accepted indication, the drug is not covered by Part D. As such, the prior authorization criteria have not been considered for review.  A physician reviewed your appeal and determined that the plan is not required to cover Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zelnorm 6 milligrams prescribed twice daily for irritable bowel syndrome with constipation. The Part D plan denied the request because the records did not support that all formulary drugs failed. 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 supporting statement and medical records were submitted. The records show Zelnorm was ordered to treat the enrollees condition. The Medicare approved compendium supports the use of the drug for this condition. However, medical records do not support that all formulary drugs for the enrollee's condition were tried and failed or would cause adverse effects or be less effective. A physician reviewed your appeal and determined that the plan not is required to cover Zelnorm.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rytary ER 61.25 milligram-245 milligram capsules to treat Parkinson's disease. 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 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 has not indicated that the enrollee has tried all alternatives required by the plan, or why the plans required step therapy drugs would likely not be as effective for the enrollee as the requested drug.  Our physician reviewer's opinion is that neither step therapy nor step therapy exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tradjenta 5 mg tablets prescribed daily for type 2 diabetes mellitus. The Part D plan denied your request for a tiering exception because Tradjenta is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative drugs. 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 systems and reviewed the enrollment data available. The record shows Tradjenta is being prescribed for type 2 diabetes mellitus. The Medicare approved compendia, supports the use of the requested drug for your condition. The plan shows Tradjenta is a brand name Tier 3 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

At issue is Horizant extended release 300 milligrams to treat chronic pain. 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 the enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amphetamine/Dextroamphetamine ER 20 milligram capsules prescribed daily for attention deficit hyperactivity disorder. The Part D plan denied your request to extend approval of the drug and quantity limit exception for an indefinite duration of time. 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 Amphetamine/Dextroamphetamine ER to treat your condition. The plan granted approval for the drug for the 2021 plan year. The plan also approved an exception to the quantity limit for the 2021 plan year. You asked the plan to allow coverage and an exception to the quantity limit for an indefinite period of time. However, Medicare rules do not require the plan to offer an exception or coverage for an indefinite duration of time. A physician reviewed your appeal and determined that the plan is not required to extend coverage beyond the timeframe noted in their approval letter for Amphetamine/Dextroamphetamine ER. This does not necessarily mean that coverage will not be available for plan year 2022. This just means you will have to resubmit a request for coverage for the 2022 plan year.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methadone 80 milligrams prescribed daily. The Part D plan denied the request because the enrollee received all the medication at a Methadone clinic. We received an auto-forwarded request from the plan to reconsider the appeal. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted.Medicare Part D does not cover Methadone when not dispensed upon a prescription at a retail pharmacy. The record shows that Methadone will be obtained from a treatment center and it was not dispensed upon a prescription at a retail pharmacy. Therefore, Methadone is not eligible for Part D coverage.We determined that the plan is not required to reimburse you for the Methadone. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha sureclick pen prescribed for hyperlipidemia. The Part D plan denied your request for a tiering exception because Repatha is a Tier 3 medication with no alternate drugs on a lower tier. We received a reconsideration request from the plan. 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 documentation shows Repatha is a biologic drug on Tier 3 of the plans formulary. There are no lower tiered biologic drugs of the same type on the lower cost sharing tiers to treat the enrollee's 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 cover Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vyvanse 10 millgrams prescribed daily for major depressive disorder. 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 Vyvanse to treat the enrollees depression. 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 Vyvanse.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diovan, 160 milligrams prescribed one daily for hypertension. You asked the Part D plan to provide a cost-sharing tiering exception. The plan denied the appeal because this drug is not listed on your formulary plan (non-formulary); however, your plan approved this drug as a formulary exception. Medicare says you cannot get a tiering exception (co-pay reduction) for a non-formulary drug approved as a 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. Your medical records show Diovan is being prescribed for hypertension. This drug is not listed in your formulary plan. However, your plan approved the drug for your use as a formulary exception. Medicare does not allow a cost-sharing exception for drugs approved as a formulary exception. Therefore, the requested drug is not eligible for a cost-sharing tiering exception (co-pay reduction).A physician reviewed your appeal and determined that the plan is not required to cover Diovan because Medicare does not allow a cost-sharing exception (co-pay reduction) for drugs approved as a formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Urea 40% cream to treat dry skin.   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 your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan denied the request for coverage of the requested drug to treat the provided diagnosis because your plan's Medicare Part D drug plan cannot cover drugs classified as being part of the Food and Drug Administration (FDA)'s Drug Efficacy Study Implementation (DESI) program. These drugs are considered to be Less than Effective (LTE) per FDA review.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine 2 milligram sublingual tablets to treat chronic pain. 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 the enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a Humira citrate-free injection kit, which contains 80 milligram/0.8 milliliter and 40 milligram/0.4 milliliter pens, prescribed as directed for moderate to severe plaque psoriasis. The Part D plan denied coverage because the prior authorization criteria were not met. Specifically, the documentation did not show that the enrollee had prior therapy with, or an intolerance, to conventional treatment options. 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 documentation shows the provider prescribed Humira to treat moderate to severe plaque psoriasis. The Medicare approved compendia do support the use of Humira for this condition.The plan requires an intolerance or contraindication to conventional therapy before they will cover the requested drug. The prescriber has not sufficiently indicated why all alternatives required by the plan would likely cause harm or not be as effective for the enrollee as 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 Humira.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is AndroGel 1.62% topical gel prescribed as directed for hypogonadism. You requested that the plan provide coverage for a non-formulary drug. The plan did not make a decision within the required timeframe. We received an 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. The physician submitted a supporting statement and medical records. The documentation shows the physician had prescribed AndroGel to treat hypogonadism. According to DRUGDEX, a Medicare approved compendium, The safety and efficacy of testosterone therapy have not been established in men with late-onset (age-related) hypogonadism.  Additionally, the prescriber has not indicated why all alternatives required by the plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee.A physician reviewed your appeal and determined that the plan is not required to cover AndroGel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lyrica Continuous Release Tablet, Extended Release, 24 hour, 165 milligrams prescribed one tablet once daily for cervicalgia, other chronic pain and unspecified osteoarthritis of unspecified site and anesthesia of skin. The Part D Plan denied the request stating that the provided diagnosis is 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 doctor prescribed Lyrica Continuous Release Tablet, Extended Release, 24 hour, to treat cervicalgia, other chronic pain and unspecified osteoarthritis of unspecified site and anesthesia of skin. The use of the requested drug to treat the provided diagnoses are off-label uses. 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 your appeal and determined that the plan is not required to cover Lyrica Continuous Release Tablet, Extended Release because you do not have a medically accepted indication.