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

You requested Xifaxan 550 milligram tablets prescribed three times daily for 14 days for other irritable bowel syndrome, abdominal distension, and bacterial intestinal infection. 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. The submitted documentation indicates your doctor prescribed Xifaxan for other irritable bowel syndrome, abdominal distension, and bacterial intestinal infection. 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.  Note also that with the Reconsideration appeal medical records were requested and were not provided.  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 Elmiron 100 milligram capsules prescribed daily for chronic intestinal cystitis. The Part D plan denied your request for a tier change request because Elmiron is in the specialty tier of your list of covered 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 plan shows Elmiron is a brand name Tier 5 drug. Your plan does not allow you to receive drugs in this tier at a lower cost share.Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a quantity limit exception for Fluorouracil 5% cream prescribed for actinic keratosis. 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 documentation indicates your doctor prescribed Fluorouracil cream for actinic keratosis. Your doctor originally requested 45 grams for a 21-day supply. Your plan allows 40 grams for a 30-day supply. Your doctor submitted a statement to request a change in billed amount to whatever is covered by your plan. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm.  An exception to the plans coverage criteria is not supported. Therefore, a quantity limit exception cannot be granted and the amount approved by the plan is upheld.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Kisqali 600 milligram tablets prescribed for malignant neoplasm of lower-outer quadrant of right female breast, HR positive, HER2 negative. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The enrollee satisfies the plan's coverage criteria. The prescriber submitted a statement and records to support the enrollee was prescribed Kisqali for malignant neoplasm of lower-outer quadrant of right female breast, HR positive, HER2 negative. In addition, the enrollee is post-menopausal, and the drug at issue is to be used as initial endocrine therapy.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ondansetron HCL 4 milligram tablets prescribed as needed for nausea and vomiting due to gastritis, gastroparesis, and acid reflux. 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Ondansetron 4 milligrams as needed to treat your nausea and vomiting due to gastritis, gastroparesis, and acid reflux. 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 the Ondansetron HCL tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate HCL 20 milligram tablets prescribed as directed for major depressive disorder. 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 Methylphenidate HCL to treat your major depressive disorder. 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 the Methylphenidate HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Opsumit 10 milligram tablets. The Part D plan denied your request because the plans prior authorization requirements were not met.  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.At reconsideration, the prescriber has submitted results from a heart catheterization report that shows the enrollee has mild pulmonary hypertension; not pulmonary arterial hypertension. The Medicare approved compendia do not contain any citations to support the use of Opsumit for the treatment of pulmonary hypertension. Therefore, the drug is being prescribed for a non-medically accepted indication 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 Opsumit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hyoscyamine Sulfate 0.125mg tablet prescribed to reduce oral secretions for an enrollee in hospice care. 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. Medicare Part D does not cover drugs that are not FDA approved for both safety and effectiveness. We determined that Hyoscyamine Sulfate is not FDA approved for both safety and effectiveness by checking FDA sources. Therefore, the plan is not required to cover Hyoscyamine Sulfate. 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

You requested Esbriet 267 milligram tablets prescribed to treat idiopathic pulmonary fibrosis. The Part D plan denied the 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 on Tier 4 which is the plans Specialty Tier. Specialty Tier drugs are not available for a tiering exception per Medicare rules.  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: Favorable

At issue is Tymlos 2 milligram/milliliter pen prescribed for severe postmenopausal osteoporosis. 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 show you prescribed Tymlos 2 milligram/milliliter pen to treat the enrollees severe postmenopausal osteoporosis. The Medicare approved compendia do support the use of this drug for this condition. The plan requires prior authorization criteria be met before they will cover the requested drug. The records submitted show the enrollee is at very high risk of fracture as evidence by a T-score of -3.5 in the lumbar spine. In addition, the records indicate that the enrollee trialed one six month dose of Prolia with subsequent adverse reaction and providers concerns for use of dual biologics. 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 Tymlos 2 milligram/milliliter pen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablets prescribed for small bowel bacterial overgrowth. 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. 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 prescriber statement indicates the drug was prescribed for the diagnosis of irritable bowel syndrome with diarrhea. However, the medical records submitted do not support this diagnosis.  The records indicate the drug is being prescribed for small intestinal bacteria overgrowth.   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 your appeal and determined that the plan is not required to cover Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Daliresp 250 microgram tablets prescribed to treat chronic obstructive pulmonary disease. 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 prescriber indicates that the medication is required every day and not just for 28 days. However, the plan limits this dosage of 250 microgram tablets to 28 tablets per 365 days. The documentation does not support the amount requested over the plans quantity limit. A physician reviewed your appeal and determined that the plan is not required to cover more than the plans quantity limit of 28 tablets per 365 days of Daliresp.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 200 milligram tablet twice daily to treat fatigue due to encephalopathy induced seizures. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rytary ER 23.75 milligram/95-milligram oral capsules prescribed daily for Parkinson disease. The Part D plan denied your request for a tiering 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. Rytary is a brand name drug on Tier 4 of the plans formulary. There are no brand name 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: Favorable

At issue is Auryxia 1 gram tablets prescribed for chronic kidney disease and hyperphosphatemia. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The enrollee satisfies the plan's coverage criteria. The prescriber submitted a statement and records to support the enrollee was prescribed Auryxia for chronic kidney disease and hyperphosphatemia. Furthermore, the records support the enrollee is on dialysis.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Leflunomide 20 milligram tablets prescribed daily for rheumatoid arthritis. 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. Leflunomide is a generic drug on Tier 4 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.A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Posaconazole 100 milligram tablet. 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 documentation indicates that Posaconazole was prescribed to treat infection due to prototheca. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition(s). Therefore, an exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Posaconazole.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Dofetilide 250 microgram capsules prescribed for paroxysmal atrial fibrillation. 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.Dofetilide is a generic drug on Tier 4 of the plans formulary. The prescribing physician has not sufficiently addressed why all of the generic drugs of the same type on the lower tiers of the plans formulary to treat the enrollees condition have been tried and failed, or are contraindicated. A physician reviewed your appeal and determined that the plan is not required to cover Dofetilide at a lower cost tiering level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Methylphenidate Hydrochloride 10 milligram tablets prescribed daily for personality and behavioral disorders due to known physiological conditions. The Part D plan denied your request because the medication was not approved by the Food and Drug Administration for the enrollees condition. 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 Methylphenidate Hydrochloride for personality and behavioral disorders due to known physiological conditions. In review of the Medicare approved compendia, personality and behavioral disorders due to known physiological conditions is not a medically accepted indication for Methylphenidate Hydrochloride. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Methylphenidate Hydrochloride at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Welchol 625 milligram tablets prescribed for diarrhea. 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 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 your appeal and determined that the plan is not required to cover Welchol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Livalo 2 milligram tablets prescribed as directed for mixed hyperlipidemia. 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 record shows the provider prescribed Livalo for an enrollee with mixed hyperlipidemia. However, the records do not show the medical reason why the enrollee cannot take other drugs on the plans formulary for the condition.A physician reviewed your appeal and determined that the plan is not required to cover Livalo.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amphetamine-Dextroamphetamine 5 milligram tablet prescribed twice daily for cancer related fatigue. 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 Amphetamine-Dextroamphetamine 5 milligram tablet to treat the enrollees cancer related fatigue. However, the Medicare approved compendia do not support the use of this drug for this condition. It is noted that your statement indicates that the enrollee also has narcolepsy, which is a medically accepted indication. However, the medical records submitted do not support a diagnosis of narcolepsy. A physician reviewed your appeal and determined that the plan is not required to cover Amphetamine-Dextroamphetamine 5 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Onfi 10 milligram tablets prescribed three times daily 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.Onfi is a non-formulary brand drug. 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 coverage for Alprazolam 0.25 milligram tablets prescribed for anxiety. The Part D plan forwarded the case 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. During this review, a request was submitted to the prescriber to address the plans coverage requirements and to provide supporting medical records. The prescriber did not reply to our request for information.The plan has prior authorization requirements that need to be satisfied prior to providing coverage for this drug. Without documentation from the prescriber, it cannot be established that these requirements have been met. A physician reviewed the appeal and determined that the plan is not required to cover the requested medication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Licart 1.3% patch prescribed for spinal stenosis of lumbar region with neurogenic claudication and knee osteoarthritis. 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. The submitted documentation indicates your doctor prescribed Licart 1.3% patch for spinal stenosis of lumbar region with neurogenic claudication and knee osteoarthritis. 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 Dimethyl Fumarate Delayed Release 240-milligram capsule to treatment multiple sclerosis. 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 record shows you were prescribed Dimethyl Fumarate Delayed Release for multiple sclerosis. However, 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. Our physician reviewer determined the requested drug is not eligible for coverage under Medicare Part D.