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

You requested Actemra 162 milligram/0.9 milliliter solution prescribed for ankylosing spondylitis. The Part D plan denied your request because the biologic 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 Actemra for ankylosing spondylitis. The Medicare approved compendia do not support the use of this biologic for your condition. As the biologic 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 drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Breztri Aerosphere, 160-9-4.8 micrograms per actuation inhalation aerosol, 1 inhaler (10.7 grams) per 2 days being prescribed for chronic obstructive pulmonary disease. The Part D plan approved your off-formulary request for the Breztri Aerosphere inhaler but denied your request for 1 inhaler per 2 days because the inhaler has a quantity limit of 1 inhaler (10.7 grams) per 30 days. 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. A physician reviewed your appeal and determined that the plan is not required to cover 1 inhaler per 2 days, as the higher dosage is not supported in the record.The plan will only allow 1 Breztri Aerosphere inhaler per 30 days. An exception to the quantity limit cannot be granted.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Creon 36,000 units extended-release capsules prescribed twice daily for pancreatic insufficiency. The Part D plan denied your request for a tiering 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.Creon is a biological drug on Tier 3 of the plans formulary. The prescriber statement shows you are being treated for pancreatic insufficiency. However, there are no biological 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 the tiering exception. There are no lower tiered biological drugs of the same type to treat your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spiriva Handihaler 18 micrograms prescribed as directed for chronic obstructive pulmonary disease. The Part D plan denied your request for a tiering exception. We received an expedited reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Spiriva Handihaler 18 micrograms 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. 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 Spiriva Handihaler 18 micrograms because there are no brand drugs of the same type on the lower cost sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dalfampridine ER 10 milligram tablet prescribed daily for cerebellar ataxia and postural instability. 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 Dalfampridine ER for cerebellar ataxia and postural instability. In review of the Medicare approved compendia, cerebellar ataxia and postural instability are not medically accepted indications for Dalfampridine ER. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Dalfampridine ER at issue. This decision does not address the medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit. The prior authorization requirements were not considered since this drug was not prescribed for a medically accepted indication. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Dalfampridine ER at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Azathioprine 50 milligram tablets prescribed as directed for other specified systemic involvement of connective tissue. 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 drug might be covered by Medicare Part A or Part B. 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 the enrollee was prescribed Azathioprine to treat other specified systemic involvement of connective tissue. The documentation does not show that the medication was prescribed following a Medicare-covered organ transplant. Therefore, the drug would not be covered under Medicare Part A or Part B, and is eligible for consideration of Medicare Part D coverage. 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 Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Modafinil 100 milligram tablets prescribed for chronic 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 Modafinil for chronic 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

At issue is Amabelz 0.5-0.1 milligram tablet prescribed daily for hormone replacement therapy. The Part D Plan denied your request for a tiering exception because the information submitted did not indicate why the enrollee could not take the lower cost drugs 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. Amabelz 0.5-0.1 milligram tablet is a branded generic drug on Tier 4 of the plans formulary. You did not address why all drugs on the lower cost-sharing tiers would not work for the enrollee. 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 Hydroxyzine Pamoate 50 milligrams prescribed for major depression. 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 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 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 Hydroxyzine Pamoate. 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 Simponi 50 milligram/0.5 milliliter injection pen prescribed for rheumatoid arthritis. The Part D plan denied your request because the documentation did not support an off-formulary exception, and 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 Simponi for rheumatoid arthritis. The documentation supports you are not taking Methotrexate in combination with Simponi for your diagnosis. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed. A formulary exception could not 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 Jadenu 360 milligram tablets prescribed as directed. 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 statement indicates the provider prefers the off-formulary brand name drug. However, the documentation does not show the medical reason why the enrollee cannot take the generic version of this drug on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Jadenu.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sucralfate 1 gram/10 milliliter suspension prescribed for gastro-esophageal reflux disease. The Part D plan denied your request to cover this drug at a lower tier cost. The plan indicated this is a non-formulary 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 Sucralfate suspension was covered as an off-formulary drug, therefore it 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 Sucralfate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 50 milligram tablets prescribed daily for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other brand 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.Myrbetriq 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. 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 Lidocaine 5% patch prescribed for sciatica, right side. The Part D plan denied your request 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 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 Lidocaine patch for sciatica. 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 prior authorization exception could not 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 Vyvanse 50 milligrams daily. 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 appeal did not include medical records to support why the enrollee cannot take other drugs on the plans formulary for their condition, or that other drugs were tried and proven ineffective. A physician reviewed your appeal and determined that the plan is not required to cover Vyvanse.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Saxenda 18 milligram/3 milliliter injection prescribed for weight loss following bariatric surgery. The Part D plan denied your request because drugs prescribed to treat weight loss do not meet the definition of Part D drugs. 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 determined that the plan is not required to cover Saxenda because it was prescribed to treat weight loss. Drugs to treat anorexia, weight loss, or weight gain 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 Armodafinil 150 milligrams prescribed for multiple sclerosis 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 Armodafinil for multiple sclerosis 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 Incruse Ellipta 62.5 micrograms inhalation prescribed for asthma. 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 Incruse Ellipta 62.5 micrograms inhalation to treat your asthma. 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 Incruse Ellipta 62.5 micrograms inhalation because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone gel pump prescribed for hypogonadism. The Part D plan denied coverage because there was insufficient documentation to support that the prior authorization criteria was met. 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 physician submitted a supporting statement. The prescriber statement indicates the physician had prescribed Testosterone and that the enrollees testosterone level was on the lower side of normal.   Relevant medical records were requested and were not provided.  The plan requires documentation confirming pretreatment serum testosterone levels. 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 Testosterone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Orencia 125 micrograms/milliliter injection prescribed for the enrollees rheumatoid arthritis. 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 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 records submitted at the reconsideration level. The documentation supports the drug was prescribed for the enrollees diagnosis of rheumatoid arthritis. However, the enrollee does not satisfy the plan's prior authorization 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 Lotemax SM 0.38% gel prescribed for severe allergy and primary open angle glaucoma. 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 Lotemax SM for severe allergy and primary open angle glaucoma. 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 Everolimus 0.75 milligram tablets prescribed twice daily for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue is on a specialty tier and is not eligible for 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.Everolimus is on the specialty tier of your plans formulary. Drugs that are on the plans specialty tier are 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 Nitro-Bid 2% ointment prescribed for vasospasms of upper extremities, acute embolism and thrombosis of deep veins of unspecified upper extremity, and Raynaud's syndrome without gangrene. 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 Nitro-Bid for vasospasms of upper extremities, acute embolism and thrombosis of deep veins of unspecified upper extremity, and Raynaud's syndrome without gangrene. 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 a tiering exception for Buprenorphin-Naloxon 8-2 milligrams sublingual. The Part D Plan denied your request for a tiering exception because the drug has already been approved at the lowest cost sharing tier available. 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. A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception. The drug is already covered at the lowest cost sharing tier available.