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

At issue is Gralise 600 milligram tablet prescribed as directed to treat post-herpetic neuralgia. 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 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 Gralise 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 the Gralise because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Megestrol 20 milligram tablets prescribed as directed for anorexia. The Part D plan denied your request because the drug was prescribed for a Medicare Part D excluded use. 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. We determined that the plan is not required to cover Megestrol. The medical records show the doctor prescribed Megestrol to treat anorexia. Drugs prescribed 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 Tymlos 3120 micrograms/1.56 milliliter injection pen prescribed daily for osteoporosis. 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 information submitted at the reconsideration level. Your medical records show your doctor prescribed Tymlos to treat your condition. Medicare approved compendia does support the use of this drug for your diagnosis. However, the documentation provided does not show the enrollee has satisfied the plan's coverage criteria. Twenty four paid claims for Tymlos are documented in the record, which is the lifetime maximum.A physician reviewed your appeal and determined that the plan is not required to cover Tymlos.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Flector 1.3 percent topical patch prescribed for a history of lumbar level 3-5 fusion and significant arthritic lumbar spine pain. 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 Flector 1.3 percent topical patch for a history of lumbar level 3-5 fusion and significant arthritic lumbar spine pain. In review of the Medicare approved compendia, a history of lumbar level 3-5 fusion and significant arthritic lumbar spine pain is not a medically accepted indication for Flector. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Flector at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Candesartan Cilexetil 32 milligram tablets prescribed daily for hypertension. 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. Candesartan Cilexetil is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated that you have tried all alternatives required by the plan, or why the plans lower tiered drugs would likely not be as effective as the requested 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 grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz 5 milligram tablets prescribed as directed for atopic dermatitis. 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 medical records show the doctor prescribed Xeljanz for atopic dermatitis. 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 Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brimonidine 0.15% eye drops prescribed for glaucoma. 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.Brimonidine is a generic drug on Tier 3 of the plans formulary. The doctor submitted a supporting statement. However, the doctor did not address why all alternative lower-tier medication on the plans formulary 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

At issue is Elmiron 100 milligram tablets. 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. There was not a diagnosis or medical records to determine if the drug is medically indicated for the enrollees condition.  A physician reviewed your appeal and determined that the plan is not required to cover Elmiron.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is an Engerix-B (Hepatitis B) vaccine 20 micrograms per milliliter suspension. The Part D plan denied the request because drugs that can be covered under Medicare Part B are not eligible to be covered under the Medicare Part D prescription drug benefit. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The documentation indicates that the Engerix-B (Hepatitis B) vaccine was prescribed because the enrollee is at high risk for contracting hepatitis B due to the presence of type 2 diabetes and stage 3 chronic kidney disease. As outlined in Medicare laws, when administered to a patient who is at intermediate to high risk of contracting hepatitis B, the vaccine is eligible for coverage under Medicare Part B. A drug prescribed for a Part D eligible individual cannot be considered a covered Part D drug if payment for the drug is available under Medicare Part A or B for that individual. We have determined that the Engerix-B (Hepatitis B) vaccine is eligible for coverage under Medicare Part B. Therefore, the Part D plan is not required to cover the drug. Please consider submitting this request to Medicare Part B. 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

You requested coverage for Tymlos 3120 micrograms per 1.56 milliliters for subcutaneous injection. The Part D plan denied the request stating that the medication was being prescribed for a non-medically accepted indication.  We received an expedited 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 indicates that the Tymlos has been prescribed for osteopenia with long-term (current) use of bisphosphonates. However, the Medicare approved compendia do not contain any citations to support the use of the medication, as prescribed, for the treatment of the noted 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 the Tymlos.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent ointment to treat active herpes. The Part D plan denied your request because the provided diagnosis 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. 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 Lidocaine 5 percent ointment because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira Pen 40 milligrams/0.8 milliliter prescribed for the treatment of neurosarcoidosis. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The 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.A physician reviewed your appeal and determined  that the plan is not required to cover Humira Pen because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate Hydrochloride 20 milligram tablet prescribed twice daily for attention-deficit/hyperactivity disorder. 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 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.Methylphenidate Hydrochloride 20 milligram tablet 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. 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 Creon prescribed twice daily for pancreatic enzyme replacement therapy. 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. 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 the listed condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate 30 milligrams prescribed daily for narcolepsy. 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. Your medical records show you were prescribed Methylphenidate for your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided does not show the coverage criteria has been met. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Methylphenidate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Leflunomide 20 milligram tablet prescribed as directed to treat rheumatoid arthritis. The Part D plan denied the request. We received an expedited 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.Leflunomide is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated that you have tried all alternatives required by the plan, or why the plans lower tiered drugs would likely not be as effective as the requested drug. 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 Lidocaine 5 percent patch prescribed for chronic pain syndrome. The Part D plan denied your request because the provided diagnosis 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. 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 Lidocaine 5 percent patch because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Aldactone 50 milligram tablets prescribed as directed. At initial determination, a diagnosis was not provided. At redetermination, the diagnoses of narcolepsy without cataplexy and circadian rhythym sleep disorder, unspecified, were given. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. The Part D plan also 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. At reconsideration, diagnoses of hypertension, androgen-dependent acne, narcolepsy with cataplexy, and lower extremity edema were given. No medical records were provided by the prescriber to support these diagnoses. 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 Aldactone.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested K Phos Original 500 milligram tablets prescribed for disorders of mineral metabolism post kidney transplant. The Part D Plan denied your request because this drug is not Food and Drug Administration-approved for both safety and effectiveness. 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. The record shows the K Phos is identified as a less than effective Drug Efficacy Study Implementation drug on the Medicare website.We determined that the plan is not required to cover the K Phos. Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. If you purchase drugs that are excluded, you must pay for them out-of-pocket. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis 0.05 percent eye solution prescribed daily for dry eye syndrome. 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. Restasis 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

At issue is Aldactone 100 milligram tablets prescribed for the treatment of androgenic hair loss. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The 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.A physician reviewed your appeal and determined that the plan is not required to cover Aldactone because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nystatin 100,000 units/gram topical powder prescribed as directed for obesity. 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 Nystatin powder for obesity. 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 Nystatin powder.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Tremfya 100 milligram per milliliter injector prescribed for hidradenitis suppurativa. 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 Tremfya for a history of hidradenitis suppurativa.In review of the Medicare approved compendia, hidradenitis suppurativa is not a medically accepted indication for Tremfya. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Tremfya at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Fioricet (butalbital 50 mg/acetaminophen 300 mg/caffeine 40 mg per capsule) prescribed for migraine headaches, craniocervical syndrome. 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 Fioricet for a history of migraine headaches, craniocervical syndrome.In review of the Medicare approved compendia, migraine headaches, craniocervical syndrome is not a medically accepted indication for Fioricet. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Fioricet at issue.