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

At issue is Ondansetron 4 milligrams to treat K21.9 (gastroesophageal reflux disease).  The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. 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: Favorable

You requested Voriconazole 200 milligrams prescribed two times daily for Coccidioidomycosis meningitis. 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. We also researched Medicare regulations and Medicare approved compendia.The record shows you were prescribed Voriconazole 200 milligrams two times daily for Coccidioidomycosis meningitis.  The following citation in AHFS-DI, a Medicare approved compendium, supports the use of the requested drug for your condition:  Voriconazole has been used for the treatment of coccidioidomycosis caused by Coccidioides immitis or C. posadasii, and is recommended as an alternative for the treatment or prevention of these infections.  Therefore, it is considered a medically accepted indication.The documentation does not satisfy the Plans coverage criteria. The Plans coverage criteria state that you need to have an FDA approved indication.  Therefore, an exception to the Plans coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate Hydrochloride Extended Release 18 milligram tablet prescribed daily for major depressive disorder, recurrent, moderate and major neurocognitive disorder due to Alzheimers disease. The Part D plan denied your request because the drug was not used for medically indicated conditions and did not meet prior authorization requirements. 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 your doctor prescribed Methylphenidate Hydrochloride Extended Release for your major depressive disorder, recurrent, moderate and major neurocognitive disorder due to Alzheimers disease. The Medicare-approved compendia do not contain citations to support that this drug is covered for your conditions. Therefore, we have determined that Methylphenidate Hydrochloride Extended Release is not being prescribed for medically accepted indications. A physician reviewed your appeal and determined that the plan is not required to cover Methylphenidate Hydrochloride Extended Release because you do not have medically accepted indications.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vraylar 1.5 gram capsules prescribed daily for dysthymic 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. We requested a prescriber statement and medical records, which were received.The records show you prescribed Vraylar 1.5 gram capsules to treat the enrollees dysthymic disorder. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Vraylar 1.5 gram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ofev (Nintedanib) 150 milligram capsule prescribed orally twice daily for idiopathic pulmonary fibrosis. The Part D plan denied your request for a tiering exception because the drug you requested is in the specialty tier; drugs placed in the specialty tier are not eligible for tiering exceptions. 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. Ofev is a brand drug on Tier 5, also known as the specialty tier, of the plans formulary. If a plan maintains a specialty tier, the plan may design its exception process so that drugs placed in the specialty tier are not eligible for a tiering exception. The record indicates the plan has chosen to exclude the specialty tier from the tiering exception process. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Ofev. A tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alprazolam ER 1 milligram tablets prescribed twice daily for generalized anxiety disorder. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your physician submitted a supporting statement. The supporting statement did not indicate formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Alprazolam ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablets prescribed twice daily for nonvalvular atrial fibrillation. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your physician submitted a supporting statement. The supporting statement did not indicate formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Eliquis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Orgovyx 120 milligram tablet to treat prostate cancer. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber has not indicated why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate Hydrochloride 20 milligrams prescribed daily for intracranial hemorrhage and amnesia. The Part D plan denied your request because the Food and Drug Administration has not approved this drug for your diagnosis. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed Methylphenidate Hydrochloride to treat your intracranial hemorrhage and amnesia. However, the Medicare approved compendia does 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 Methylphenidate Hydrochloride. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ondansetron 4 milligrams prescribed as needed for nausea and vomiting due to abdominal pain. The Part D plan denied your 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. 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 abdominal pain. 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 Ondansetron 4 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Acyclovir 5% ointment prescribed twice daily for zoster without complication. 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 medical records and prescriber statement show Acyclovir cream was prescribed to treat zoster without complication with associated severe pain and rashes due to postherpetic neuralgia. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Acyclovir 5% cream. The medical record does not include a medically accepted indication for the drug at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Flovent HFA Aerosol (Fluticasone Propionate), 110 micrograms 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.Flovent HFA Aerosol (Fluticasone Propionate), 110 micrograms is a brand  drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Topiramate 100 milligram tablets prescribed two times daily for trigeminal neuralgia. 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 Topiramate for trigeminal neuralgia. 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: Favorable

At issue is Testosterone Cypionate 200 milligrams per milliliter, injection to treat idiopathic/secondary hypogonadotrophic hypogonadism. The Part D plan denied the request. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The documentation satisfies the plans coverage criteria. Additional medical records at the reconsideration level support, based on Medicare compendia, the drug is for a medically accepted indication. Prior authorization criteria are met for continuation of therapy in this male who had documented low testosterone levels on multiple occasions.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Metolazone 25 milligrams prescribed for advanced renal disease and refractory hypertension. The Part D plan denied your request for a formulary exception. We received an expedited 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 Metolazone to treat your advanced renal disease and refractory hypertension. The Medicare approved compendia support the use of this drug for your condition. Your doctor submitted a prescriber statement indicating that a loop diuretic was tried and your hypertension was not well controlled. He also states that a thiazide type diuretic would not be helpful. However, the plan formulary includes other drugs that could be used to treat your condition. Your records do not show that all alternative drugs on the plan formulary have been tried or why you cannot take them. This decision does not address the medical necessity of the requested drug. It only means that it cannot grant a formulary exception for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Afinitor 10 milligram tablets prescribed as directed for breast cancer. 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. The documentation shows the doctor prescribed Afinitor for an enrollee with metastatic hormone receptor positive, HER2 negative breast cancer. The prescriber statement submitted at reconsideration indicates the enrollee will be using Afinitor in combination with Exemestane after failure of treatment with Letrozole. However, the medical records submitted for review do not support this statement. The prescriber statement and medical records previously submitted to the plan show the enrollee was prescribed Afinitor in combination with Anastrozole. There is insufficient documentation to show the enrollee is using Afinitor for an indication that is supported by the Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Afinitor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 500 milligram tablets prescribed twice daily for dermatomyositis. The Part D plan denied your request because the medically accepted indication criteria was not met. 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. The medical records show Mycophenolate Mofetil was prescribed to treat dermatomyositis. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Mycophenolate Mofetil. The medical records submitted do not show the enrollee has a medically accepted indication for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Humulin R U-500  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.This drug is being provided by the plan 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 Sildenafil Citrate 20 milligram tablets prescribed three times daily for unspecified pulmonary hypertension. 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 Sildenafil Citrate for unspecified pulmonary hypertension. 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 Vraylar 1.5 milligram capsules prescribed daily for major depressive disorder. The Part D plan denied your request because for a drug with step therapy requirements 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 medical records show Vraylar was prescribed for major depressive disorder. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Saphris, 5 milligram sublingual tablets. The Part D Plan denied your request for a lower-cost tiering exception because the medication is included in the plans specialty tier. 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. A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.Saphris is listed on the Part D plans formulary as Tier 5, which is the tier for specialty drugs. The plan does not grant tiering exceptions for specialty drugs. Therefore, this drug is not eligible for coverage at a lower-cost tier.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Temazepam 7.5 milligrams prescribed twice daily for insomnia. The Part D Plan denied your request for a tiering exception. We received an expedited auto-forwarded reconsideration request from the plan. 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 shows the enrollee was prescribed Temazepam 7.5 milligrams to treat insomnia. The Medicare approved compendium support the use of the requested drug for the enrollees condition. Temazepam is a generic drug on Tier 4 of the plans formulary. The prescriber statement shows Doxepin from Tier 3 was tried and deemed to be either less effective or have increased side effects. The plans formulary does not include other lower tier generic alternatives of the same type to treat the enrollees condition. A physician reviewed your appeal and determined that the plan is required to cover Temazepam 7.5 milligrams.
Appeal type: Prescription Drug
Decision: Favorable

You requested a Tetanus, Diptheria, and Pertussis (DTAP) vaccine. The claim was originally reviewed incorrectly as a Medicare Part B claim and was not timely reviewed by the plan. We received an expedited 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.The record shows you received a Tetanus, Diptheria, and Pertussis (DTAP) vaccination from your prescribers office. You submitted a copy of the bill including proof of payment in full for the requested vaccine. We determined that the plan is required to cover the Tetanus, Diptheria, and Pertussis (DTAP) vaccine.