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

At issue is Hetlioz 20 milligram tablet prescribed daily for circadian rhythm sleep disorder, free running type. The Part D plan denied coverage because medical necessity was not established. 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 records show Hetlioz was prescribed to treat circadian rhythm sleep disorder, free running type. The Medicare approved compendia do support the use of this drug for this condition. However, the plan requires prior authorization criteria be met before they will cover the drug. The documentation provided does not show the enrollee has satisfied the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xopenex HFA Aerosol to treat chronic obstructive pulmonary disease and chronic respiratory failure. The Part D plan denied your request for a non-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 records 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 Trimethobenzamide 300 milligram capsules for Parkinsons disease. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. 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. The submitted documentation indicates Trimethobenzamide was prescribed as a measure to prevent nausea and vomiting prior to starting a new treatment for the enrollees condition. 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 Cimzia Syringe Kit (200 milligram/milliliter X 2) to treat other specified inflammatory spondylopathies, site unspecified. 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.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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 Ursodiol 300 milligram tablets prescribed twice daily for primary biliary cirrhosis. The Part D plan denied your request for a tiering exception. 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. Ursodiol 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. A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oracea 40 milligram capsule prescribed for rosacea. The Part D plan denied your request for a tiering exception because there are no lower tier alternatives of the same type for your 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. Oracea 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. There is no brand drug on a lower eligible tier of the same type that is used to treat your condition. Therefore, your plan is not required to offer you a lower cost share.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Xgeva 120 milligrams per 1.7 milliliter. 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. Medical records were requested from your doctor during this review, but not received.The Part D plan is responsible for ensuring that covered Part D drugs are prescribed for medically accepted indications. The submitted documentation does not include any medical records from your physician stating what condition your medication is being prescribed for. Therefore, there is insufficient information to determine if the Xgeva is being prescribed for a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to cover the Xgeva.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xiidra 5% solution to treat dry eye syndrome. The Part D plan denied your request for a non-formulary exception. 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 tried Restasis. However, medical records have not been submitted for review. Therefore, the documentation available 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 Xiidra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Motegrity 2 milligram tablet prescribed as directed to treat constipation. 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 Motegrity to treat your condition.The medical records do not show all alternative drugs on the plans formulary have been tried and failed, or would likely be ineffective. 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 the Motegrity because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine	Hydrochloride 8 milligram sublingual tablets prescribed for other spondylosis lumbar region. The Part D plan denied your request because the Food and Drug Administration has not approved the use of this drug for the diagnosis provided. 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 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 Part D.A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride sublingual tablets. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil treat multiple sclerosis related fatigue. We received an expedited reconsideration request. We performed and independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation submitted. We also researched Medicare regulations and Medicare approved compendia. 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 Part D.   Our Physician Reviewers opinion is that the plan is not required to cover Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Accu-chek Aviva Plus Test Strips.  The Part D plan denied the request because these supplies could be covered under Medicare Part B and are not eligible to be covered under the Medicare Part D Prescription Drug benefit. 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. We also researched Medicare systems and reviewed the enrollment data available.Based on the information provided, we determined these diabetic supplies would be eligible for coverage under Part B under Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyzulta 0.024% ophthalmic solution prescribed for glaucoma. The Part D plan denied your request for a tiering exception because the drug is not on the plans formulary. 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. Vyzulta 0.024% is a brand drug that is not on the plans formulary. The plan agreed to cover this drug at the cost sharing level associated with non-formulary drugs. You may not request a tiering exception for a non-formulary prescription drug. 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 Vyzulta 0.024% at a lower cost.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Colchicine 0.6 milligram tablet prescribed daily for prevention of pseudogout attacks. The Part D plan denied the request because there was no 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.Colchicine 0.6 milligram tablet was ordered for prevention of pseudogout attacks. 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 the Colchicine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gralise Extended Release (ER) 300 milligram tablets prescribed for spinal stenosis and peripheral neuropathy. The Part D plan denied your request because the Food and Drug Administration has not approved the use of this drug for the diagnosis provided. 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 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 Part D.A physician reviewed your appeal and determined that the plan is not required to cover Gralise ER. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diltiazem hydrochloride ER 24 hour 360 milligram capsules prescribed for 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. The prescriber submitted a statement to the plan. However, the documentation does not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Diltiazem hydrochloride ER 24 hour 360 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trintellix 10 milligram tablet prescribed for depression. The Part D plan denied your request for a tiering exception because there are no lower tier alternatives of the same type for your 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. Trintellix 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. There is no brand drug on a lower eligible tier of the same type that is used to treat your condition. Therefore, your plan is not required to offer you a lower cost share.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Thalidomide 100 milligram capsules prescribed daily for angiodysplasia of stomach and duodenum with bleeding. 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. 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 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 Thalidomide because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate HCL 10 milligrams tablets to treat chronic fatigue in an enrollee with sleep apnea and multiple sclerosis.  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 prescriber initially provided the diagnosis of sleep apnea and fatigue due to multiple sclerosis.  In a letter dated 3/2/2021, the prescriber changed the diagnosis to  attention-deficit/hyperactivity disorder.  However, the provided medical records support the diagnoses of sleep apnea and chronic fatigue with multiple sclerosis.  Medical records were not provided to support the diagnosis of attention-deficit/hyperactivity disorder. 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

You requested Cyclobenzaprine hydrochloride 10 milligram tablets prescribed as directed for chronic muscle spasm related to lumbar postlaminectomy syndrome. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. The Part D plan also stated the prior authorization critieria were not met. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The documentation shows the doctor prescribed Cyclobenzaprine hydrochloride for chronic muscle spasm related to lumbar postlaminectomy syndrome. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. Prior authorization cannot be approved if the drug is not prescribed for a medically accepted indication; therefore, the prior authorization criteria have not been considered for review. A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 50 milligram tablets prescribed daily for overactive bladder. The Part D plan denied your request for a tiering exception. 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. Myrbetriq ER 50 milligram tablets are a brand drug on Tier 3 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 cover Myrbetriq ER 50 milligram tablets because there are no brand drugs of the same type on the lower cost sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Vascepa 1 gram capsules. The Part D Plan denied your request for a tiering exception because there were no other similar drugs on a lower cost-sharing 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 cover the Vascepa at a lower cost tier.Vascepa is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. Therefore, a tiering exception cannot be granted for the Vascepa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil 20 milligram tablet prescribed daily 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 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 determined that the plan is not required to cover Sildenafil. 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 Nexletol 180 milligrams tablets. The Part D plan denied your request to cover this drug at a lower tier cost. The plan indicated this is a non-formulary approved drug and cannot be provided at a lower tier cost. 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 Nexletol was prescribed; however, Nexletol is a non-formulary approved drug and is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception for the Nexletol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tacrolimus 0.1% ointment prescribed for perioral and periorificial dermatitis. The Part D plan denied your request because the diagnoses provided do 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 Tacrolimus 0.1% ointment to treat your perioral and periorificial dermatitis. However, the Medicare approved compendia do not support the use of this drug for your conditions. A physician reviewed your appeal and determined that the plan is not required to cover Tacrolimus 0.1% ointment because your diagnoses do not meet the Medicare requirement of medically accepted indications.