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

You requested Gabapentin 600 milligram tablets prescribed 270 tablets for 30 days for neuropathic pain. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication and a quantity limit exception could not be granted. 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 Gabapentin for neuropathic pain. 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 quantity limit exception could not be granted as the drug was not prescribed for a medically accepted indication.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 Amphetamine-dextroamphetamine ER 15 milligram capsules prescribed as directed. At initial determination and redetermination, the diagnosis of major depressive disorder was given. 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. An additional prescriber statement shows the diagnosis of major depressive disorder, and indicates the enrollee also has a diagnosis of attention-deficit hyperactivity disorder or attention deficit disorder. The medical records provided support a diagnosis of major depressive disorder. No medical records were provided by the prescriber to support the additional diagnoses listed. 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 your appeal and determined that the plan is not required to cover Ampehetamine-Dextroamphetamine ER.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Hetlioz 20 milligram capsules prescribed for circadian rhythm sleep disorder, free running type. The Part D plan denied the request. We received a standard 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. We also researched Medicare regulations and Medicare approved compendia. The documentation includes office visit notes supporting a sleep apnea study was negative for apnea and sleep logs are stated to be consistent and classic for non-24 hour circadian rhythm pattern, free running. Therefore, the prior authorization requirements were met.   A physician reviewed your appeal and determined that the plan is required to cover Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Aranesp 60 microgram/ 0.3 syringe prescribed as directed for thalassemia. The Part D plan denied the request because it does not meet the criteria of 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 record shows you were prescribed Aranesp to treat your condition. 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 Aranesp because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide inhalation solution. The Part D plan denied your request for this 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 information submitted at the reconsideration level. This drug is eligible for coverage under Medicare Part B. Medicare Part B covers this drug, when used with a nebulizer in the home. Medicare Part D cannot pay for drugs that are covered by Medicare Part B.We determined that the plan is not required to cover Budesonide.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Epolamine 1.3% patch prescribed for myalgia and spinal stenosis. 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 Diclofenac Epolamine for myalgia and spinal stenosis. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil Citrate 100 milligram tablets prescribed for erectile dysfunction. The Part D plan denied your request because drugs prescribed to treat sexual or erectile dysfunction do not meet the definition of Part D 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 determined that the plan is not required to cover Sildenafil Citrate because it was prescribed for erectile dysfunction. The medical records submitted support the drug at issue was prescribed for erectile dysfunction. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Singulair 10 milligram tablets 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 case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Singulair is not on the plans formulary. The prescriber has not supplied a supporting statement, along with medical records, to explain 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.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 Meloxicam 5 milligram capsules prescribed twice daily. 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 plan requested additional information from the prescriber. No medical records were provided. 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 your appeal and determined that the plan is not required to cover Meloxicam.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 500 milligram capsules prescribed for polymyositis with lung involvement. 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 Mycophenolate Mofetil for polymyositis with lung involvement. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Perforomist 20 microgram/2 milliliter solution prescribed twice daily for asthma. 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 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 record shows Perforomist was prescribed to treat asthma. The requested drug is being used via small volume nebulizer. According to Medicare rules, Medicare Part B pays for the rental and purchase of durable medical equipment. Payment will also be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. Therefore, coverage under Part D is excluded for any drug for which payment would be available under Part B.We determined that the plan is not required to cover Perforomist. 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. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tretinoin 0.1% cream prescribed for rosacea. 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 Tretinoin for rosacea. Your doctor submitted a statement to change the prescribed diagnosis to acne vulgaris; however, there were no medical records submitted to support the change in diagnosis. 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 Elmiror 100 milligrams capsules to treat severe interstitial cystitis. 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. This drug is at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Aldactone 100 milligram tablets prescribed daily for narcolepsy and circadian rhythm disorder. 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 Aldactone for narcolepsy and circadian rhythm disorder. Your doctor submitted a statement to change the prescribed diagnosis to hypertension and androgen dependent acne; however, there were no medical records submitted to support the change in diagnosis. 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 Testoterone 1.62% Pack for late-onset hypogonadism. 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. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The Medicare approved compendia indicates the safety and efficacy of testosterone replacement therapy for men with late-onset hypogonadism have not been established.  A physician reviewed your appeal and determined that the plan is not required to cover Testosterone 1.62% Pack.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gattex Kit. The Part D plan denied a request for this drug because you did not have 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. The documentation indicates that Gattex was prescribed to treat short bowel syndrome. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition(s) due to not being dependent on parenteral support. A physician reviewed your appeal and determined that the plan is not required to cover Gattex.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine 10 milligram tablet prescribed three times a day for muscle spasms. 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 records submitted at the reconsideration level. The prescriber was asked questions to address the Plans prior authorization criteria. A response from the prescriber was not received. Your medical records show you were prescribed Cyclobenzaprine to treat your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided do not show the plan's coverage criteria has been met.A physician reviewed your appeal and determined that the plan is not required to cover the Cyclobenzaprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Butabital, Aspirin, Caffeine, and Codeine 50mg/325mg/40mg/30mg capsule prescribed four times a day for chronic migraine without aura, intractable, without status migrainosus. The Part D plan denied coverage because the prior authorization criteria were not met. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level. The prescriber was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the Plans prior authorization criteria. A response from the prescriber was not received. Your medical records show you were prescribed Butabital, Aspirin, Caffeine, and Codeine to treat your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided do not show the plan's coverage criteria has been met.A physician reviewed your appeal and determined that the plan is not required to cover the Butabital, Aspirin, Caffeine, and Codeine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tadalafil 20 milligram tablets prescribed as directed for erectile dysfunction. The Part D plan denied your request because drugs being used for the treatment of erectile dysfunction are excluded from coverage by Medicare Part D. We received a reconsideration request. We received a 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 determined that the plan is not required to cover Tadalafil. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Temazepam 30 milligram capsule prescribed as directed for insomnia. 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. Your medical records show you were prescribed Temazepam for your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The record 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 Temazepam.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Omega 3 acid ethyl esters 1 gram capsule. The Part D plan denied the request. We received an auto-forward 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. No medical records were provided by the prescriber. 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 your appeal and determined that the plan is not required to cover the Omega 3 acid ethyl esters because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aubagio 14 milligram tablets prescribed for Multiple Sclerosis. The Part D plan denied the request for a formulary exception. We received an expedited 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 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. A physician reviewed your appeal and determined that the plan is not required to grant your request for a formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mesalamine Enema 4 gram/60 milliliter prescribed for ulcerative colitis. The Part D plan denied the request for a tiering exception. We received an expedited reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Mesalamine Enema is a generic drug on Tier 4 of the plans formulary. There are no generic same type drug on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Cyclosporine Modified 25 milligram capsules prescribed following a kidney transplant. 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 an expedited reconsideration request.  We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your records show your doctor prescribed Cyclosporine Modified to prevent rejection following a kidney transplant. The Medicare approved compendia support the use of this drug for your condition. Based on the information provided, the drug is not eligible for Part B coverage.  Therefore, the drug is eligible for Part D coverage in this case.   A physician reviewed your appeal and determined that the plan is required to cover Cyclosporine Modified.