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

Section 1860D-2(e)(4) of the Social Security Act defines medically-accepted indication, in part by reference to Section 1927(k)(6) of the Social Security Act, to any use of a covered Part D drug which is approved under the Federal Food, Drug, and Cosmetic Act, or the use of which is supported by one or more citations included or approved for inclusion in any of the compendia described in Section 1927(g)(1)(B)(i) of the Social Security Act. The recognized compendia are: 1) American Hospital Formulary Service Drug Information, and 2) DRUGDEX Information System.Part D sponsors are responsible for ensuring that covered Part D drugs are prescribed for medically-accepted indications using the tools and data available to them to make such determinations. Part D sponsors must reference all the Centers for Medicare & Medicaid Services recognized compendia to determine whether there are any supportive citations, prior to determining that a drug is not being used for a medically-accepted indication. Part D sponsors may rely on utilization management policies and procedures, approved by the Centers for Medicare & Medicaid Services where required (see Section 30.2.2.1), to make such determinations. Dispensing pharmacists are not required to contact each prescriber to verify a prescription is being used for a medically-accepted indication. Additionally a Part D drug must be used for a medically-accepted indication that facilitates the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member (except for Part D vaccines). Consequently, if a drug works on medical equipment or devices and is not used for a medically accepted indication of therapeutic value on the body, it cannot satisfy the definition of a Part D drug. For example, a heparin flush is not used to treat a patient for a medically accepted indication, but rather to dissolve possible blood clots around an infusion line. Therefore, heparins use in this instance is not therapeutic but is, instead, necessary to make durable medical equipment work. Heparin would therefore not be a Part D drug when used in a heparin flush. [Sections 1860D-2(e)(4) and 1927(k)(6) of the Social Security Act; Prescription Drug Benefit Manual, Chapter 6, Section 10.6]
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Creon 36,000 units prescribed daily for exocrine pancreatic insufficiency. 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. Creon 36,000 units is a biologic drug on Tier 3 of the plans formulary. There are no biologic 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 Creon 36,000 units because there are no biologic brand drugs of the same type on the lower cost sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Viagra 100 milligrams for erectile dysfunction. The Part D plan denied your request because agents used for the treatment of sexual or erectile dysfunction are excluded for Part D coverage. 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 determined that the plan is not required to cover Viagra 100 milligrams because the records submitted indicate that the drug is prescribed for sexual or erectile dysfunction. 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

You requested Sildenafil 25 milligrams prescribed three times daily for pulmonary hypertension. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Sildenafil 25 milligrams three times daily to treat your pulmonary hypertension. 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 Sildenafil 25 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dupixent, 300 milligram per 2 milliliter auto injector for the treatment of dermatitis, unspecified. The Part D plan denied your request because the medication is not approved to treat your condition. 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. The medical records show your doctor prescribed Dupixent to treat dermatitis brought on by eosinophilic dermatosis of hematologic malignancy. 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 Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Leukine 250 micrograms/vial prescribed once per week for metastatic pancreatic cancer. 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 Leukine to treat metastatic pancreatic cancer. The medical records show the enrollee has been treated with multiple chemotherapies in the past and is currently on surveillance, with no detectable disease. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Leukine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Briviact (brivaracetam), 50 milligrams prescribed one tablet to be taking two-times-daily for unspecified convulsions. Your Part D plan denied Briviact because the approved compendia did not support its use for unspecified convulsions. The accepted use of the drug requires a diagnosis of partial-onset-seizures. Therefore, you did not meet the requirements for this 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. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Briviact to treat your unspecified convulsions. The Medicare approved compendium does not support the use of Briviact for unspecified convulsions. The accepted use of Briviact is for partial-onset-seizures. Your plan requires that you must have a covered condition before they will consider covering the requested drug. The documentation provided 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 cover Briviact because you do not have a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Azathioprine 50 milligram tablets prescribed as directed for serpiginous chorioretinitis, an inflammatory eye disease. The Part D plan denied your request because the drug might be covered by Medicare Part A or Part B. The Part D plan also denied your request because the drug was not prescribed for a medically accepted indication. In addition, the Part D plan denied your request because the drug requires prior authorization. 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 Azathioprine to treat serpiginous chorioretinitis. 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 serpiginous chorioretinitis. Since the drug is not prescribed for a medically accepted indication, the drug is not covered by Part D. As such, 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 Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine 10 milligrams prescribed three times daily for neck spasms. The Part D plan denied the request because it does not meet the criteria of a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The record shows you were prescribed Cyclobenzaprine 10 milligrams three times daily for neck spasms. 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 the Cyclobenzaprine because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 500 milligram tablets prescribed twice daily following a kidney transplant. The Part D plan denied the request because 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 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. We also researched Medicare systems and reviewed the enrollment data available.We determined that the drug is not eligible for Part B coverage. The records show the enrollee underwent a kidney transplant on February 1, 2002, and was covered under Medicare Part A. 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. Medicare systems show that the enrollee was covered under Medicare Part A beginning May 1, 1999, and Medicare Part B beginning July 1, 2000. Drugs used as immunosuppressive agents for aftercare following a transplant would be billable to Medicare Part B and are not covered under the Part D drug coverage benefit. Therefore, we have determined that the plan is not required to cover Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dapsone 5% gel prescribed for cicatricial alopecia. The Part D plan denied your request because the medication is 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 record shows you prescribed Dapsone 5% gel to treat the enrollees cicatricial alopecia. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Dapsone 5% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cresemba 186 mg capsules prescribed for the prevention of fungal infections. The enrollee is undergoing chemotherapy treatment for acute myeloblastic leukemia. The Part D plan denied your request because the off-label use of the drug for the enrollees condition is not medically accepted per Medicare rules. 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. We also researched Medicare regulations and Medicare approved compendia. The prescriber submitted information that indicates the enrollee is undergoing chemotherapy treatment for a diagnosis of relapsed acute myeloblastic leukemia. The prescriber states that the treatments lead all patients to become immunocompromised and neutropenic during each cycle of chemotherapy thus putting the enrollee at risk of deadly opportunistic infections such as fungal pneumonia. However, Medicare approved compendia do not support the use of this drug for prevention but only for treatment of fungal disease. Medicare requires that the drug must be prescribed for a medically accepted indication that is approved by the FDA or supported by one or more citations in Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Cresemba.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trulicity 0.75 milligram prescribed weekly for type II diabetes. The Part D plan denied your request for a tiering exception because there are no lower tier biologic alternatives for the enrollees condition. 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.Trulicity is a biologic drug on Tier 3 of the plans formulary. There are no lower tier biologic drugs of the same type on the plan's formulary to treat the enrollee's 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 reimburse Trulicity at a lower tier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Otezla dose pack prescribed daily for hidradenitis suppurativa. The Part D plan denied your request because this is not 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.Otezla was ordered to treat the enrollees above diagnosis. However, the Medicare approved compendia do not support the use of the drug for this condition.A physician reviewed your appeal and determined that the plan is not required to cover Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amphetamine-Dextroamphetamine tablet 10 milligrams prescribed for the diagnoses of cognitive fatigue and impaired attention after a cerebrovascular accident. The Part D plan denied your request because the diagnoses did not meet the requirement of a medically accepted indication. 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. We also researched Medicare regulations and Medicares approved compendia. The prescriber submitted information that indicates the enrollee has residual symptoms of a cerebrovascular accident which include cognitive fatigue and impaired attention. The physician states that the enrollee had derived significant benefit from the use of neurostimulant medication for the past 2 years. However, Medicare approved compendia do not support the use of this drug for these conditions. Medicare requires that the drug must be prescribed for a medically accepted indication that is approved by the FDA or supported by one or more citations in Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Amphetamine-Detroamphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Calcipotriene and Betamethasone Dipropionate 0.005/0.064% prescribed daily for dyshidrotic eczema. 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. 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 asked your prescriber to send us information regarding your condition. We asked for medical records or other documentation to show why you need the medication. Specifically, we requested records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation. Your physician submitted a prescribers statement and letter. The records show that the physician prescribed Calcipotriene and Betamethasone Dipropionate to treat your dyshidrotic eczema. The physician stated that this drug gave the most relief. The plan formulary includes other drugs that could be used to treat your condition. However, the records do not show all alternative drugs on the plan formulary have been tried and why you cannot take them.  This decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit. A physician reviewed your appeal and determined that the plan is not required to cover an off-formulary exception for Calcipotriene and Betamethasone Dipropionate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuplazid 34 milligram capsules prescribed daily for neuroleptic induced Parkinsonism. 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 your doctor prescribed Nuplazid to treat a drug induced movement disorder. However, the Medicare approved compendia do not support the use of this drug for neuroleptic induced Parkinsonism. A physician reviewed your appeal and determined that the plan is not required to cover Nuplazid.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armour Thyroid 120 mg prescribed daily for hypothyroidism. The Part D plan denied your request because the drug is not covered under the plan. 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. We also researched Medicare systems and reviewed the enrollment data available.We determined that the plan is not required to cover Armour 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

You requested Tadalafil 5 mg, prescribed daily for benign prostatic hyperplasia. The Part D plan denied your request because the plans prior authorization criteria was not met. 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 Tadalafil to treat benign prostatic hyperplasia. The Medicare approved compendia do support the use of this drug for your condition. The medical records show that you are allergic to Tamsulosin and have contraindications with Doxazosin and Terazosin. However, the records do not show that you have tried 5-alpha reductase inhibitor medications and/or why you cannot take them. The plan requires that you have tried 5-alpha reductase inhibitors before requesting Tadalafil. Therefore, the records do not support that prior authorization criterion was met for the drug.    A physician reviewed your appeal  and has determined that the plan is not required to cover Tadalafil because the prior authorization criterion was not met.