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

At issue is Tadalafil 5 milligram tablets prescribed daily for benign prostate hyperplasia. The Part D plan denied coverage because the prior authorization criteria were not met. 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 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 Tadalafil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 100 milligrams prescribed for erectile dysfunction. The Part D plan denied your request because the medication is excluded from coverage under Part D. We received a reconsideration request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Sildenafil Citrate 100 milligrams for erectile dysfunction.Medicare law excludes certain drugs from Part D coverage. Sildenafil Citrate is one of those excluded drugs because it is a drug used to treat sexual or erectile dysfunction. Therefore, the Plan is not required to cover Sildenafil Citrate. 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 Sensipar 30 milligrams prescribed once daily for end-state renal disease. The Part D plan denied your request because this drug may be eligible for coverage under Parts A or B; therefore, it cannot be covered under Part D. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows Sensipar was ordered for the treatment of end-stage renal disease. Drugs that are end-stage renal disease or acute kidney injury related are bundled into an end-stage renal disease payment bundle.  Therefore, we have determined that the drug is bundled into the end-stage renal disease payment bundle. The plan is not required to cover the drug.  You may wish to submit this request to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Modafinil 200 milligram tablets prescribed as directed for excessive daytime sleepiness. 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 prescriber statement indicates the enrollee has hypersomnia and obstructive sleep apnea. The sleep study submitted for review states the enrollee has excessive daytime sleepiness, but it does not show a diagnosis of obstructive sleep apnea. The sleep study also states that the enrollee does not have narcolepsy. 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 Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Praluent Soln Auto-inj 75 milligrams/milliliter to treat coronary artery disease, peripheral artery disease, and hyperlipidemia. 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. Praluent Soln Auto-inj 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 Praluent Soln Auto-inj 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 Dronabinol 10 milligrams capsules. The Part D plan denied a request for this drug because you did not have 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 documentation shows Dronabinol was prescribed to treat cervicalgia. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latuda 120 milligram tablets prescribed for bipolar disorder. The Part D plan denied your request for a tier change request because Tetrabenazine is in the specialty tier of your list of covered drugs. 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 record shows Latuda is being prescribed for bipolar disorder. The Medicare approved compendia support the use of the requested drug for your condition. The plan shows Latuda is a brand name Tier 5 drug. Your plan does not allow you to receive drugs in this tier at a lower cost share.Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entocort EC 3 milligram capsules prescribed for immunoglobulin A nephropathy prophylaxis. This is a non-formulary request. The Part D plan denied the request. 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 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.Our Physician Reviewers opinion is that the plan is not required to cover Entocort EC 3 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Siliq 150 milligram injection to treat Hurley stage III, hidradenitis suppurativa. 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. Your medical records show your doctor prescribed Siliq 150 milligram injection to treat your Hurley stage III, hidradenitis suppurativa. 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 Siliq 150 milligram injection because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Linzess 290 microgram 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. Linzess 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 Linzess.A physician reviewed your appeal and determined that the plan is not required to cover the Linzess at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acetazolamide 250 milligram tablets prescribed for Meniere's disease. The Part D plan denied your request for a tiering exception because the requested drug was not prescribed for 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. Your medical records show your doctor prescribed Acetazolamide 250 milligram tablets to treat your Meniere's disease. However, the Medicare approved compendia do not support the use of this drug for your condition. Per Medicare rules, drugs that are not prescribed for a medically accepted indication 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

At issue is Venofer 100 milligram/5 milliliter vial needed for therapy. The Part D plan denied the request because Medicare does not cover injectable iron products. 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 reviewed the plans formulary and evidence of coverage. Venofer is not a covered drug under the enrollees Part D plan. According to Medicare rules, the drug may be eligible for coverage under Part B in certain settings. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 10 milligram tablets to treat other spondylosis, lumbosacral region. The Part D plan denied your request. We received a reconsideration request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. 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. The drug is not approved by the food and drug administration to treat the diagnoses submitted. 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 Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 2.5 milligram capsule to be given twice a day for severe malnutrition. The Part D plan denied the drug because it was not medically necessary. The plan requires prior approval before covering some drugs. If prior approval is not obtained, the plan may not cover the drug. We received 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.Dronabinol is being requested to treat severe malnutrition. 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Revlimid 15 milligram capsule to treat the enrollees condition. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Revlimid is a brand name drug on Tier 5 of the plans formulary. There are no brand name drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception. 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 coverage for Xeljanz XR, 11 milligram extended release tablets. The Part D plan denied the request stating that the medication was 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 submitted documentation indicates that Xeljanz XR has been prescribed to treat inflammatory polyarthropathy. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted conditions. 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 Xeljanz XR.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Somatuline Depot 90 milligrams/0.3 milliliter solution for refractory chronic gastrointestinal bleeding related to angioectasias. The Part D plan denied coverage because the condition was 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. The medical records show Somatuline Depot was prescribed to treat refractory chronic gastrointestinal bleeding related to angioectasias. However, the Medicare approved compendia does not support the use of this drug for your condition.  A physician reviewed your appeal and determined that the plan is not required to Somatuline Depot.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Austedo 6 milligram tablets. At initial determination and redetermination the diagnosis of restless legs was given. The Part D plan denied the request stating that the provided diagnosis is 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 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 doctor indicated the correct diagnosis is tardive dyskinesia. However, the progress note shows Austedo was prescribed for restless legs and anxiety interfering with sleep. The records do not support the change in prescribing diagnosis. They do not support the diagnosis change to a drug that was prescribed for a medically accepted indication in accordance with the Medicare approved compendia. 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 Sildenafil Citrate 20 milligram tablet to treat erectile dysfunction.   The Part D plan denied the request.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not FDA approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Mycophenolate Mofetil 500 milligrams prescribed for interstitial pneumonia with autoimmune features and undifferentiated connective tissue disease with pulmonary involvement. 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 Mycophenolate Mofetil for interstitial pneumonia with autoimmune features and undifferentiated connective tissue disease with pulmonary involvement. In review of the Medicare approved compendia, interstitial pneumonia with autoimmune features and undifferentiated connective tissue disease with pulmonary involvement is not a medically accepted indication for Mycophenolate Mofetil. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Mycophenolate Mofetil at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cosentyx 300 milligram dose syringe prescribed for pityriasis rubra pilaris. The Part D plan denied your request. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed Cosentyx to treat your condition. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Cosentyx. 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 Tetrabenazine 12.5 milligram tablets prescribed four times daily for orofacial dyskinesia. 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 Tetrabenazine for orofacial dyskinesia. This is an off-label use for the drug. 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 Neurontin 100 milligram capsules prescribed three times daily for pain and chronic headaches. 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. Your medical records show your doctor prescribed Neurontin 100 milligram capsules three times daily to treat your pain and chronic headaches. 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 Neurontin 100 milligram capsules because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz XR, 11 milligram extended release tablets. The Part D Plan denied your request for a lower-cost tiering exception because the medication is included in the plans specialty 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. Xeljanz XR is listed on the plans formulary as Tier 5, which is the tier for specialty drugs. The plan does not grant tiering exceptions for specialty drugs. Therefore, this drug is not eligible for coverage at a lower-cost tier. A physician reviewed your appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine HCl/Naloxone HCl 2 milligram/0.5 milligram tablets prescribed for chronic pain. 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 Buprenorphine HCl/Naloxone HCl for chronic pain. 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.