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

At issue is Azathioprine 50 milligram tablet prescribed as directed following a heart transplant. The Part D plan denied your request because this drug may be eligible for coverage under Part B; therefore, it cannot be covered under Part D. 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 other information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The record shows you that your doctor prescribed Azathioprine following your heart transplant. According to Medicare records, you were enrolled in Medicare Part A when your kidney transplant was performed on February 9, 2005. Therefore, Azathioprine is covered under Medicare Part B. Drugs that are eligible for Part B coverage are excluded from Part D coverage by Medicare law.As such, our decision is that the Part D plan is not required to cover the Azathioprine. This decision does not refer to the medical necessity of the requested drug. It only establishes that payment cannot be made under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ondansetron 5 milligrams for nausea and vomiting due to reflux and bloating. 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 Ondansetron was prescribed for nausea and vomiting due to reflux and bloating. 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 Testosterone 1% (50 milligrams/5 gram) packets prescribed for the enrollees testicular hypofunction. The Part D plan denied coverage because the plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received 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 documentation supports the drug was prescribed for testicular hypofunction. However, the prescriber has not sufficiently addressed the plans coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gamunex-C 5 grams/50 milliliters prescribed as directed for autoimmune autonomic neuropathy. The Part D plan denied your request because the provided diagnosis 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 Gamunex-C  to treat your autoimmune autonomic neuropathy. 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 Gamunex-C because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Lumigan 0.01% ophthalmic solution 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.Lumigan 0.01% ophthalmic solution 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 Xifaxan (Rifaximin) 550 milligram tablet prescribed for small bowel bacterial overgrowth and bloating. The Part D plan denied your request because the diagnosis provided does not meet the requirements of a Food and Drug Administration 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 Xifaxan to treat your small bowel bacterial overgrowth and bloating 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 Xifaxan because your diagnosis does not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone cypionate 200 milligram/milliliter injectable solution prescribed weekly for low testosterone. The Part D plan denied your request for a tiering exception. We received an 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. Testosterone cypionate is a generic drug on Tier 3 of the plans formulary. There are no generic drugs of the same type on the lower cost sharing tiers to treat the enrollees 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: Unfavorable

At issue is Megestrol Acetate 40 mg  tablets to treat decreased appetite post stroke..  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: Unfavorable

At issue is Hydroxyzine pamoate 25 milligrams. 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.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 Hydroxyzine pamoate because it can not be established that the drug is being prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested sodium phenylbutyrate prescribed as directed for amyotrophic lateral sclerosis. 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. Your medical records show your doctor prescribed sodium phenylbutyrate to treat your condition. 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 drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Calcitriol .25 microgram capsules prescribed for end stage renal disease. The Part D plan denied the request because the drug is end stage renal disease related and not covered under Medicare Part D. 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. According to Medicare rules, the requested drug is eligible for coverage under the Part B end stage renal disease payment bundle. Drugs which are eligible for Part B coverage are excluded from Part D coverage. We determined that the plan is not required to cover the Calcitriol. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for the compound drug of Interferon Alpha 2B 1 million international units per milliliter and water (vial), for an ophthalmic solution, to treat the diagnosis of eye cancer. The Part D Plan denied the request because compound 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 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.We note this drug is a compounded drug. Interferon alpha-2B ingredient is on the plans formulary. However, 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. The plan approved coverage for this compounded drug through July 20, 2021. Coverage cannot be continued under Part D after that time as the diagnosis provided is not a medically accepted indication.  The plan allowed coverage under Part B. A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone hydrochloride ER 10 milligram tablets prescribed as directed. You requested that the plan provide coverage for a drug that has prior authorization criteria. The plan did not make a decision within the required timeframe. 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 asked your prescriber to send us a statement regarding your condition. We also asked for medical records to show why you need this medication. We did not receive the documentation requested.No medical records were provided by the prescriber to support the need for this medication. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. In addition, there was insufficient documentation to show that you have satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Oxycodone hydrochloride ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol Sulfate HFA Inhalation Aerosol Solution108 (90 base) one gram/30 days prescribed for coughing. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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. Medicare approved compendia supports the use of the requested drug for your condition. However, the records do not show why you cannot take other drugs on your plans formulary for your condition. These may include Albuterol HFA, ProAir, and Ventolin HFA.A physician reviewed your appeal and determined that the plan is not required to cover Albuterol Sulfate HFA.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin ER 60 milligram tablets prescribed for cervical disc disorder with radiculopathy. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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 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 Oxycontin ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested NP Thyroid 60 milligram tablets prescribed daily for hypothyroidism. The Part D plan denied your request because the drug is not covered under the plan. We received an auto-forwarded reconsideration request from the plan. 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 NP Thyroid because it is not covered under the Part D plan. In addition, drugs that are not Food and Drug Administration approved are excluded from coverage. This drug is not approved under the Food and Drug Administration guidelines. Your plan does not offer 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 Bumetanide 1 milligram prescribed for chronic kidney failure. The Part D plan denied your request for a tiering exception because the prescriber did not address all alternatives were tried and failed. 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.Bumetanide is a generic drug on Tier 3 of the plans formulary. We requested information from the physician as to why all alternative lower-tier medication on the plans formulary would not work for the enrollees condition. All generic drugs on lower tiers have not been tried. 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 Omeprazole 20 milligrams prescribed daily for acid reflux. The Part D plan denied your request because over-the-counter drug products are excluded from coverage under Medicare Part D. 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 Omeprazole 20 milligrams because it is an over-the-counter drug product. Nonprescription, or over-the-counter drugs, 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 Gammaplex (Immune Globulin) Solution prescribed twice daily for autoimmune autonomic ganglionopathy. The Part D plan denied your request because the diagnosis provided does not meet the requirements of a Food and Drug Administration 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 Gammaplex Solution to treat your autoimmune autonomic ganglionopathy. However, the Medicare approved compendium 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 Gammaplex Solution because your diagnosis does not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rasuvo (Methotrexate) Auto-Injector 15 milligrams/0.3 milliliters subcutaneously for rheumatoid arthritis. The Part D plan denied your request for a non-formulary exception because your prescriber did not give medical reasons explaining why the preferred drugs would not work just as well. 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 Rasuvo Auto-Injector for your rheumatoid arthritis. This drug is not on the plans formulary list. Additionally, your doctor did not explain why the requested Rasuvo Auto-Injector is preferred over the plans current covered formulary drugs used to treat your condition. There is no indication your doctor has tried you on covered formulary drugs with documentation of the results or if the drugs would likely cause adverse events and/or would be less effective than the non-formulary drug Rasuvo Auto-Injector.A physician reviewed your appeal and determined that the plan is not required to cover Rasuvo Auto-Injector because the medical records do not indicate why the non-formulary drug is preferred over current drugs on the plans formulary to treat your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem tartrate 12.5 milligrams prescribed as directed to treat insomnia. 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 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 that your doctor prescribed Zolpidem tartrate to treat your condition. Your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover Zolpidem tartrate because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Dupixent 300 milligrams/2 milliliters prescribed for atopic dermatitis.   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.  The prescriber clarified the medical history in a letter dated 2/25/2021.  The prescriber states the enrollee has tried and failed Prednisone, Clobetasol, Triamcinolone, Eucrisa, Sarna and most recently Protopic. Medical records from date of service 2/25/2021 were provided which documented that the enrollee tried Protopic and had adverse effects with burning and worsening of symptoms.  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Calcipotriene 0.005% ointment applied topically twice daily for transient acantholytic dermatosis. The Part D plan denied the drug because it was not medically necessary. The plan requires prior approval before covering some drugs. If prior approval is not obtained, the plan may not cover the drug. 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 records submitted at the reconsideration level.Calcipotriene 0.005% ointment is being requested. 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 the Calcipotriene 0.005% ointment.