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

You requested Ondansetron 8 milligram tablets prescribed for nausea and vomiting and Crohns disease. 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 Ondansetron for your condition. 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 Ondansetron.
Appeal type: Prescription Drug
Decision: Favorable

You requested Lidocaine 5% patch prescribed for post-herpetic neuralgia. The Part D plan denied your request.We received the case to perform 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 submitted with the Reconsideration appeal show that Lidocaine 5% patch is being used to treat the enrollees post-herpetic neuralgia. The Medicare approved compendia do support the use of this drug for your condition. The plan requires documentation of post-herpetic neuralgia and trial and failure of one other agent used to treat post-herpetic neuralgia, such as Gabapentin, before they will cover the requested drug. The medical records submitted indicate that the enrollee uses both the Lidocaine 5% patch and Gabapentin to treat their post-herpetic neuralgia. Therefore, Gabapentin alone has not relieved the enrollees post-herpetic neuralgia. As such, the documentation provided does show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Multaq 400 milligram tablets prescribed for the enrollees condition. The Part D plan denied your 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.Multaq is a brand drug on Tier 3 of the plans formulary. There are no brand drugs to treat the enrollees condition 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 Vascepa one gram prescribed two capsules twice a day for chronic ischemic heart disease. The Part D Plan denied your request for a tiering exception because there are no brand drugs available in the lower tier(s) for your 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. Vascepa is a brand drug on Tier 2 of the plans formulary. The prescriber statement shows you have tried Lipitor. However, your doctor did not address why all alternative lower-tier medication on the plans formulary would not work for you. 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 coverage for Lidocaine 5% patches. The Part D plan forwarded the request to us for review.  We received the case to perform 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.Part D sponsors are responsible for ensuring that covered Part D drugs are prescribed for medically accepted indications. The documentation indicates that Lidocaine 5% patches have been prescribed for the treatment of low back pain. During this review, a prescriber statement and supporting medical records were requested from the prescriber to address the diagnosis of low back pain. However, the prescriber did not respond to the request. Without clarifying documentation from the prescriber, it is not possible to determine if the medication is being prescribed for a medically accepted indication and eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine 5% patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Diclofenac Epolamine 1.3% patch. The Part D plan denied the request for coverage.  We received the case to perform 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 indicates that Diclofenac Epolamine has been prescribed for the treatment of long-term pain in an enrollee with lymphoma and gastrointestinal issues. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug for the treatment of long-term pain. Therefore, the drug is being prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the Diclofenac Epolamine patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuedexta 20-10-milligram capsule to treat pseudobulbar affect. The Part D plan denied the 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 provided addressed the plans coverage criteria, and those criteria were not satisfied. 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 Armodafinil 150 milligram tablets prescribed for circadian rhythm disorder. The Part D plan denied your 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 Armodafinil for circadian rhythm disorder. Your doctor submitted a statement that indicated the diagnosis should be shift work sleep disorder; however, the medical records submitted indicate the drug at issue was prescribed for primary circadian rhythm disorder. The Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined that the drug was 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 Actemra 162 milligrams/0.9 milliliter ACTPen prescribed as directed for adult onset Stills disease. The Part D plan denied your request.We received the case to perform 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 Actemra ACTPen to treat your adult onset Stills disease. However, the Medicare approved compendia do not support the use of this drug for your condition. 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 Orenitram Extended Release 2.5 milligram tablets prescribed for Raynauds disease. 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 Orenitram for Raynauds disease. 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 Envarsus XR 1 milligram tablets for kidney transplant status. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. We also researched Medicare systems and reviewed the enrollment data available.We asked the prescriber to send us a prescriber statement and medical records to show why the enrollee needs this medication. We did not receive the documentation requested.The documentation available for review does not show why the enrollee cannot take other drugs on the plans formulary for his/her condition. A physician reviewed your appeal and determined that the plan is not required to cover Envarsus XR.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate Hydrochloride 10 milligram tablets prescribed for chronic fatigue. 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 Methylphenidate Hydrochloride for your chronic 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. A physician reviewed your appeal and determined that the plan is not required to cover Methylphenidate Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Humira Citrate Free Pen Crohns Ulcerative Colitis 80-milligram to treat microscopic colitis. The Part D plan denied the 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 the treatment 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

At issue is Aliskiren 300 milligram tablet prescribed to treat the enrollee's condition. The Part D plan denied your request for a tiering exception.We received the case to perform 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 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.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 Dupixent 300 milligrams per 2 milliliter to treat the enrollees condition. The Part D plan did not make a decision.We performed an independent and de novo review. To make our decision, we read all documentation submitted. This includes any information submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the documentation requested.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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 Invega Extended Release 9-milligram tablet. At initial determination and redetermination the diagnosis of other psychotic disorder was given. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  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.At reconsideration a diagnosis of undifferentiated schizophrenia was given. No medical records were provided by the prescriber to support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. 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 Procrit 40000 units/milliliter prescribed for unknown diagnosis. 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 prior authorization forms had conflicting answers, and there are no supporting medical documentations submitted.  The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records.  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 Corlanor 5 milligram tablets prescribed for congestive heart failure with restrictive cardiomyopathy. The Part D plan denied your request.We received the case to perform 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 Corlanor 5 milligram tablets to treat the enrollees congestive heart failure with restrictive cardiomyopathy. The medical records submitted indicate that the enrollee has sinus tachycardia. The Medicare approved compendia do not support the use of this drug under these circumstances. It is also noted that the enrollee does not meet the prior authorization criteria based on the documentation provided. A physician reviewed your appeal and determined that the plan is not required to cover Corlanor 5 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Imbruvica 420 milligram tablets prescribed for the enrollees condition. The Part D plan denied your 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.Imbruvica is a tier 4 drug on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier are 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 coverage for Gabapentin 600 milligram tablets, 2 tablets to be taken 4 times a day, which totals 4800 milligrams per day (240 tablets per 30-day supply) prescribed for cervical and lumbar radicular pain. The Part D plan denied your request.We received the case to perform 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 part D plan has a quantity limit for Gabapentin of 180 tablets per 30 days, which is 3600 milligrams (six tablets) per day. The documentation does not support the necessity for exceeding the maximum dose allowed by the plan. An exception to the quantity limit criteria has not been met. A physician reviewed your appeal and determined that the plan is not required to cover 240 tablets of Gabapentin per 30-day supply.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablets to treat the diagnoses of small intestinal bacterial overgrowth and constipation. The Part D plan denied your request.We received the case to perform 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 diagnoses 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 conditions. 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Livalo 4 milligram tablets for 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 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 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

You requested Darifenacin ER 7.5 milligram tablets. The Part D plan denied your request.We received the case to perform 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 requested drug is being provided by your plan under a formulary exception. Darifenacin 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 non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

You requested Boostrix Tdap vaccine prescribed for vaccination. The Part D plan denied your request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows you received the Boostrix vaccine from your physician on August 17, 2020. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. According to your plan's Evidence of Coverage, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The plans formulary shows the drug is covered as a Tier 3 drug. The documentation submitted includes a receipt indicating you paid for the vaccine in full and the physicians office waived the administration fee. We determined that the plan is required to reimburse you for their share of the cost for the Boostrix vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Potassium Chloride 20 milliequivalent ER tablets prescribed for chronic obstructive pulmonary disease and asthma. The Part D plan denied your 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 Potassium Chloride ER tablets for chronic obstructive pulmonary disease and asthma. The Medicare approved compendia do not support the use of this drug for your condition. As it cannot be determined that the drug was 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 Humalog 100 units per milliliter injection to treat the enrollees condition. The Part D Plan denied the request.We received the case to perform 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 indicates that Humalog is being administered at home via an infusion pump. Therefore, we have determined that the drug is not eligible for Part D coverage, but would be covered under DME in Medicare Part B.A physician reviewed your appeal and determined that the Part D plan is not required to cover Humalog 100 units per milliliter injection.