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

You requested Sildenafil Citrate, 20-milligram tablet prescribed once daily for Jackhammer Esophagus. The Part D plan denied your request because your diagnosis is not a Food and Drug Administration supported 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. Your medical records show your doctor prescribed Sildenafil Citrate to treat your prediabetes. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Sildenafil Citrate because you do not have a medically accepted indication per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cresemba 186 milligram capsules prescribed daily for encounter for prophylactic measures unspecified and myelodysplastic syndrome, unspecified. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Cresemba for encounter for prophylactic measures unspecified and myelodysplastic syndrome, unspecified. In review of the Medicare approved compendia, encounter for prophylactic measures unspecified and myelodysplastic syndrome, unspecified are not medically accepted indications for Cresemba. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Cresemba at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vyvanse 20 milligram capsules prescribed daily for binge eating disorder. The Part D plan denied your request because the medication is not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The statement you submitted indicates you prescribed Vyvanse to treat the enrollees binge eating disorder. Medicare approved compendia do support the use of this drug for this condition.  However, you have not submitted medical records to support the diagnosis listed on the statement you submitted.A physician reviewed your appeal and determined that the plan is not required to cover Vyvanse.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mitomycin ophthalmic solution 5 milligrams prescribed as directed for malignant neoplasm of unspecified conjunctiva. The Part D plan denied your request because it does not meet the criteria of 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Mitomycin ophthalmic solution 5 milligrams to treat your malignant neoplasm of unspecified conjunctiva. 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 Mitomycin ophthalmic solution 5 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate Succinate 10 milligram tablets were prescribed three times daily for Parkinsons disease-related 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 the drug for Parkinsons disease-related 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pennsaid 2% topical solution for shoulder and back pain. 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 the drug for shoulder and back 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 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 Retacrit 10,000 units/milliliter prescribed for monoclonial gammopathy. The Part D plan denied the request because drug 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. The record shows Retacrit will be administered by a physician. Therefore, this drug is eligible for coverage under Medicare Part B. Drugs that are administered as part of the physicians service are covered under Medicare Part B.We determined that the plan is not required to cover Retacrit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine HCl Urethral/Mucosal Gel 2% prescribed 30 milliliters every three days for rectal polyps. The Part D plan denied your request for a quantity limit exception request. 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 documentation indicates your doctor prescribed Lidocaine HCl to treat your rectal polyps. The plan only allows 30 milliliters per 30 days. An exception to the quantity limit criteria was not met.Therefore, the plan is not required to cover Lidocaine for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Eylea 2 milligram/0.5 milliliter intravitreal injection prescribed every four weeks as directed for age-related wet macular degeneration. The Part D plan denied the request 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 information submitted at the reconsideration level. The record shows the physician prescribed Eylea to treat age-related wet macular degeneration. This injectable drug is administered intravitreally (inside the eye) by the physician. However, this drug is eligible for coverage under Medicare Part B. Drugs provided incident to a physician service are eligible for coverage under Medicare Part B, and excluded from coverage under Medicare Part D. Therefore, the prior authorization criteria have not been considered for review. We determined that the plan is not required to cover Eylea.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregnyl 10,000 unit solution to treat erectile dysfunction. The Part D Plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Folic acid 1 milligram prescribed as directed for folate blockage or depletion. The Part D plan denied your request because the requested drug is a prescription vitamin. We received a 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. We also researched Medicare systems and reviewed the enrollment data available. We determined that the plan is not required to cover Folic acid 1 milligram because it is a prescription vitamin and mineral product. Drugs prescribed for prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations 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

You requested Modafinil 200 milligram tablets prescribed daily for multiple sclerosis. The Part D plan denied your request because 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. Your medical records show your doctor prescribed Modafinil to treat your fatigue associated with multiple sclerosis. However, the Medicare approved compendia do not support the use of this drug for your condition.A physician reviewed your appeal and determined that the plan is not required to cover Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Veberzi, 75 milligrams prescribed daily for irritable bowel syndrome with diarrhea. Your Part D plan denied the appeal because Veberzi is a Specialty Tier drug and is not eligible for a cost-share 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 records submitted at the reconsideration level. The record shows your doctor prescribed Veberzi to treat your irritable bowel syndrome with diarrhea. Your plans formulary shows that Veberzi is a Tier 4, Specialty Tier drug. Medicare does not allow a cost-sharing tiering exception for a Specialty Tier drug.A physician reviewed your appeal and determined that the plan is not required to cover Veberzi because a Specialty Tier drug is not eligible for a cost-share tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Meclizine Hydrochloride 12.5 milligram tablets to treat bilateral vertigo of central origin. The Part D plan denied the request. We received an auto-forwarded reconsideration request from the coverage level.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.Meclizine Hydrochloride is a generic drug on Tier 2 of the plans formulary. There are no generic 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 a tiering exception request for Mybetriq 50 milligram extended release tablet to treat overactive bladder. The Part D plan denied the request. We received an auto-forwarded reconsideration request from the coverage level.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.Mybetriq is a brand drug on Tier 3 of the plans formulary. There are no brand drugs 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 Myrbetriq 50 milligram 24 hour extended release tablet prescribed daily for urinary incontinence. 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. Myrbetriq is a brand drug on Tier 4 of the plans formulary. There are no brand 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: Unfavorable

At issue is Nuedexta capsule prescribed for pseudobulbar affect. The Part D plan denied coverage because there was insufficient documentation to support that the prior authorization criteria were met. 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 records submitted at the reconsideration level. The physician submitted a supporting statement. The prescriber statement indicates that the enrollee has been stable on the requested medication.However, the plan requires documentation that the enrollee does not have the presence of prolonged QT interval, congenital long QT syndrome, heart failure, or a history of torsades de pointes. Medical records have not been submitted for review. The documentation submitted provides conflicting information.The documentation available for review does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Nuedexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Febuxostat 40 milligram tablets prescribed for gout. The Part D plan did not provide a timely redetermination decision. 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The prescriber states that the enrollee had tried Allopurinol which did not control the enrollees symptoms. The Medicare approved compendia supports the use of this drug for your condition. The plan requires a step therapy approach prior to approving Febuxostat. The plan requires Allopurinal be tried prior to moving to step 2 which is Febuxostat. However, there were no medical records to support the enrollees history or medications used in the past. The requested information was not received. The documentation provided was insufficient to support the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Febuxostat.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Balsalazide disodium 750 milligram capsules prescribed as three capsules twice a day for ulcerative pancolitis. The Part D Plan denied your request for a tiering exception because  the documentation did not support why other drugs in a lower tier could not be used to treat the enrollees condition. 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 asked the prescriber to send us a prescriber statement with information about the enrollees condition. We also asked for medical records to show why the enrollee needs the medication. Specifically, we asked for records to show why similar medications on the lower tiers would not work for this enrollee. We received documentation and included it in our review.Balsalazide disodium is a generic drug on Tier 4 of the plans formulary. The doctor submitted a supporting statement. The statement said you could not tolerate other drugs due to an allergy. However, the medical records submitted do not support this statement. There is insufficient documentation in the medical records to support that all generic drugs on lower tiers cannot be used to treat this enrollee. 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 Metoprolol Tartrate 75 milligrams per tablet as directed. The Part D plan denied your request for a tiering exception because the drug you requested is a non-formulary 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 information submitted at the reconsideration level. The record shows you were prescribed Metoprolol Tartrate 75 milligrams per tablet. Since the drug isnt on the plans formulary it is not eligible for a tiering exception. 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 Metoprolol Tartrate 75 milligrams per tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested lidocaine 5% patch prescribed for meralgia paresthetica. The Part D plan denied your request because the diagnosis is not 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 medical records show Lidocaine 5% patch was prescribed to treat meralgia paresthetica. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover the lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Buprenorphine Hydrochloride, 8 milligram sublingual tablets. The Part D plan denied coverage of the medication stating that they did not receive enough information from the physician to determine if the drug was being prescribed for a medically accepted indication.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. A physician reviewed your appeal and determined that the plan is required to cover the Buprenorphine Hydrochloride. The medical records submitted at reconsideration show that the doctor prescribed Buprenorphine Hydrochloride to treat the enrollees opioid dependence. The Medicare approved compendia do support the use of this drug for this condition. Additionally, the medical records support the Part D plans prior authorization requirement, which is the requested drug is being prescribed for induction therapy for transition from opioid use to treatment of opioid use disorder, has been met.Therefore, the documentation provided at reconsideration supports coverage of the Buprenorphine Hydrochloride by the Part D plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lyrica 150 milligrams prescribed as directed for pain related to cancer and the treatment. The Part D plan denied the request because it does not meet the criteria of 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 record shows you were prescribed Lyrica for pain related to cancer and the treatment. 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 Lyrica because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Avycaz 2.5 gram vial to treat chronic pansinusitis. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare.