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

You requested Ursodiol 300 milligram capsules for primary biliary cholangitis. 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 reviewed your appeal carefully. We reviewed all documentation available. The submitted documentation indicates your doctor prescribed the drug for primary biliary cholangitis. Your doctor prescribed the 300 milligram capsules. The Medicare approved compendia do not support this is a medically accepted indication for this method of delivery. 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 Pylera prescribed for your condition. The Part D plan denied your request. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read all documentation submitted.The documentation included a diagnosis but did not include any medical records. We are unable to determine the drug was for a medically accepted indication without medical records.A physician reviewed your appeal and determined that the plan is not required to cover Pylera.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Humira 80-40 Pen Injection Kit prescribed for pyoderma gangrenosum. 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. The submitted documentation indicates your doctor prescribed Humira for pyoderma gangrenosum. The Medicare approved compendia do not support this is a medically accepted indication. As Humira 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 Humira.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz to treat rheumatoid 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 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 Febuxostat 40 milligrams prescribed for gout. The Part D plan denied your request because the Food and Drug Administration had no approved this drug for your diagnosis. 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 medical record supports you have been diagnosed with gout. The Medicare approved compendia support the use of this drug for your condition.   However, the plan's prior authorization criteria require a history of inadequate response, or intolerance to Allopurinol.  This information was not supported by the submitted medical records.A physician reviewed your appeal and determined that the plan is not required to cover Febuxostat.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zolpidem Tartrate 5 milligrams prescribed for insomnia. 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 reviewed your appeal carefully. We reviewed all documentation available. The submitted documentation indicates your doctor prescribed the drug for insomnia. Your doctor indicated you have been on the drug since 2019. There are no medical records submitted to support the request.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 Tamsulosin Hydrochloride 0.4 milligram capsule prescribed for unknown diagnosis. The documentation shows the enrollee . We received an auto-forwarded request from the plan to reconsider the appeal.We conducted an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review.The record shows the enrollee purchased one Tamsulosin Hydrochloride capsule. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. A request for reimbursement was submitted to the plan. There were no errors in the cost sharing amount charged.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Effexor 150 mg. 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 reviewed all documentation submitted.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. Non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Propranolol Hydrochloride Extended Release 160 milligrams prescribed daily for migraine prophylaxis and atrial arrhythmia. The Part D Plan denied your request for a tiering exception because there was insufficient documentation from your physician to support that drugs on the lower tier for your condition would be less effective or would have adverse effects. 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. Propranolol Hydrochloride is on Tier 3 of the plans formulary. The prescriber statement shows that some of the drugs would either be inappropriate or not as effective. However, he did not account for all the lower tier drugs. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Carbamazepine 200mg tablet to treat the enrollees condition. 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 appeal carefully. We reviewed all available documentation.Carbamazepine 200mg tablet is a generic drug on Tier 2 of the plans formulary.The prescriber has not indicated that you have tried all alternatives required by the plan, or why the plans lower tiered drugs would likely not be as effective as the requested drug. Therefore, this drug is not eligible for a tiering exception.Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armour Thyroid 30 milligrams prescribed for hypothyroidism. 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. Your physician submitted a supporting statement. The supporting statement did not indicate 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 Armour Thyroid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Apriso capsules .375gm to treat the enrollees unspecified condition. 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 appeal carefully. We reviewed all available documentation.This drug is being provided by the 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

At issue is a tiering exception request for Oxtbutynin 5 milligram tablet to treat an unknown diagnosis. 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 reviewed all documentation submitted.There are no brand 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. Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Colestipol Hydrochloride one gram tablet to treat Crohn's disease.  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.  The use of the requested drug to treat the provided diagnosis is an off-label use.  The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methamphetamine at an unspecified dose to treat type I narcolepsy. 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 appeal carefully. We reviewed all available documentation.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Suboxone 8/2 film to treat opioid use disorder. 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 appeal carefully. We reviewed all available documentation.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zelnorm 6 milligram tablets prescribed for chronic constipation. The Part D plan denied the request because the manufacturer of the drug at issue did not participate in the Medicare Gap Discount Program. We received a request from the appellant to reconsider the appeal. 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 manufacturer of the drug at issue, AlfaSigma, does not participate in the Medicare Gap Discount Program. Payment cannot be allowed for a drug whose manufacturer does not participate in the Medicare Gap Discount Program.We determined that the plan is not required to cover the drug at issue.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Repatha 140 milligrams/milliliter Sureclick pen to treat hyperlipidemia in an enrollee with coronary artery 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 the case file carefully. We reviewed all documentation submitted. The prescriber sent medical records and clarified the medical history in the request for reconsideration. The enrollee has achieved documented LDL-C reduction while on Repatha. The enrollee's LDL-C on November 10, 2020, was 128 milligrams/deciliter. The enrollee's LDL-C on February 3, 2021, was 68 milligrams/deciliter.The documentation satisfies the plans coverage criteria.  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Premarin .625 milligram vaginal cream to treat an unspecified diagnosis. 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 appeal carefully. We reviewed all available documentation.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5 mg tablet to treat postural orthostatic tachycardia syndrome, orthostatic hypotension, and disorder of the autonomic nervous system. 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. Medical records were provided. The prescriber states the enrollee's ejection fraction is 55-60%. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vancomycin Hydrochloride powder.  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 drug product is to be compounded using the bulk powder form of the drug.  A Medicare Part D drug is one approved by the Food & Drug Administration (FDA). The bulk powder form of this drug is not approved by the FDA, and not covered.  Our Physician Reviewer's opinion is that this medication is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amphetamine-Dextroamphetamine 10 milligrams prescribed three times a day for obstructive sleep apnea with hypersomnia. The Part D plan denied your request because the Food and Drug Administration has not approved the use of this drug for the diagnosis provided. 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 Medicare approved compendia does 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 Amphetamine-Dextroamphetamine. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Favorable

You requested Repatha 140 milligram/milliliter injection prescribed for dyslipidemia and atherosclerosis. The Part D plan denied your request because the prior authorization criteria were not met. 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 medical records show the doctor prescribed Repatha to treat dyslipidemia and atherosclerosis. The Medicare approved compendium does support the use of this drug for this condition. The documentation provided shows the enrollee has satisfied the plan's coverage criteria. Therefore, your medical records support that the plans prior authorization requirements have been satisfied.We determined that the plan is required to cover the Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Calcium Acetate 667 milligram tablet to treat hyperphosphatemia. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted.Based on the information provided, we determined the drug would be eligible for coverage under Part B. 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 Calcitriol 0.25 microgram capsule to treat a diagnosis that was not provided. 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 reviewed all documentation submitted.Based on the information provided, we determined the drug would be eligible for coverage under Part B. 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 Orencia Clickjet 125 milligram/milliliter to treat rheumatoid 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 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

At issue is Tretinoin 0.05% topical cream prescribed for unknown diagnosis. 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. There is insufficient documentation to verify if the drug can be covered by the Part D Drug plan.A physician reviewed your appeal and determined that the plan is not required to cover the Tretinoin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estradiol 1 milligram. 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 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 does not contain evidence of a diagnosis. There are no medical records submitted to indicate the prescribed diagnosis. Therefore, there is no evidence the drug was prescribed for a medically-accepted indication.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

You requested reimbursement for self-administered medications during your observation stay at the hospital. The Part D plan denied your request because stating they needed additional information from the hospital. 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 you were billed and paid for self-administered drugs during your observation stay including Buspirone 10 milligram ($3.00), Venlafaxine 75 milligrams ($19.75), Metformin 500 milligrams ($0.50), and Amlodipine five milligrams ($34.75).We determined that the plan is required to reimburse you for the multiple medications.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methocarbamol 500 milligrams prescribed for muscle spasm and osteoarthritis. 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 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

At issue is a tiering exception request for Vascepa 1 gram capsule to treat hypertriglyceridemia.   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.Vascepa 1 gram capsule is a brand drug on Tier 3 of the plans formulary. There are no brand 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. Our Physician Reviewer's opinion is that tiering exception criteria are not met.