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

You requested Mesalamine DR, 400 milligrams, four capsules prescribed twice daily for other specified noninfective gastroenteritis and colitis. Your Part D plan denied your request because this drug is not being prescribed for a medically accepted indication. This means that it is not being used for a disease or condition that is either approved by the Food and Drug Administration or that is supported by one or more of the Medicare-approved compendia.  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 Mesalamine DR to treat lymphocytic colitis. However, the Medicare approved compendium do not support the use of this drug for your condition.A physician reviewed your appeal and determined that your plan is not required to cover Mesalamine DR because the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aimovig 140 milligrams/milliliter injection prescribed as directed for the prevention of migraines. The Part D plan denied your request for a tiering exception the drug is considered a biologic drug, and there are no biologic drugs available on a lower tier of the plans formulary. 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. Aimovig 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 Aimovig.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gralise 600 milligram tablets prescribed as directed. The Part D plan denied your request for a tiering exception because the drug you requested is not included 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.Gralise is a brand drug, which is not included on the plans formulary. The plan agreed to cover the drug, but the plan does not provide tiering exceptions for non-formulary drugs approved as formulary exceptions. 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 Gralise.
Appeal type: Prescription Drug
Decision: Unfavorable

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

At issue is Dexmethylphenidate 10 milligrams as directed prescribed for attention deficit hyperactivity disorder. The Part D Plan denied your request the documentation did not explain why alternative drugs in a lower tier were not tried or would not work just as well. 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 you were prescribed Dexmethylphenidate 10 milligrams as directed for attention deficit hyperactivity disorder. The Medicare approved compendia support the use of this drug to treat your condition. However, your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them.A physician reviewed your appeal and determined that the plan is not required to cover Dexmethylphenidate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Entyvio, 300 milligram injection for the treatment of collagenous colitis. The Part D plan denied your request because collagenous colitis is not a Food and Drug Administration-approved diagnosis for the use of this medication. 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 the Entyvio because you do not have a medically accepted indication to use this drug.Your medical records show your doctor prescribed Entyvio to treat collagenous colitis. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law.  As such, the requested drug does not meet the definition of a Medicare Part D drug and is therefore not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Praluent Pen Injector 75 milligrams/milliliters prescribed 2 milliliters per 28 days for aftercare following a cardiac stent placement. 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 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 the plans coverage information.The medical records show the physician had prescribed Praluent for treatment after receiving a cardiac stent. A Medicare approved compendium supports the use of the requested drug for your condition. However, the drug is not on the plans formulary.A formulary exception can be allowed if the enrollee has tried other drugs on their plans formulary that treat the same diagnosis or condition or have a medical reason not to try the formulary alternative. The prescriber stated the enrollee could not afford Repatha Sureclick but did not address a medical reason for not trying the formulary alternative. The records do not show why other drugs, on your plans formulary for your condition, have not been tried. A physician reviewed your appeal and determined that the plan is not required to cover Praluent Pen Injector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Biktarvy tablets prescribed once a day for the diagnosis of human immunodeficiency virus. The Part D Plan denied your request for a tiering exception because the drug is in the plans specialty Tier and is excluded from the tiering exception process. We received a request for an expedited reconsideration. 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 regulations and reviewed the plans tiering exception process. If the plan maintains a specialty tier, the plan may design its exception process so that drugs placed in the specialty Tier are not eligible for a tiering exception. Biktarvy is a brand drug on the plans specialty Tier of the plans formulary. 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 Biktarvy.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine 10 milligram tablets prescribed for skeletal muscle spasms due to a chronic musculoskeletal condition. The Part D plan denied your request because the medication is 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 records show you prescribed Cyclobenzaprine 10 milligram tablets to treat the enrollees muscle spasms secondary to a chronic musculoskeletal condition. 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 Cyclobenzaprine 10 milligram tablets. We cannot overturn a high risk determination for a drug the Part D plan cannot cover.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent patch prescribed as directed for osteoarthritis of the right hip. 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. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Lidocaine 5 percent patch as needed to treat your osteoarthritis of the right hip. However, the Medicare approved compendia do not support the use of this drug for your condition. Additionally, the plan requires prior authorization criteria for the Lidocaine 5 percent patches to be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria. 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

At issue is Morphine sulfate ER 30 milligrams prescribed as directed for pain control. The Part D Plan denied your request because the documentation did not explain why alternative drugs in a lower tier were not tried or would not work just as well. 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 you were prescribed Morphine sulfate ER 30 milligrams as directed for pain control. The Medicare approved compendia support the use of this drug to treat your condition. However, your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them.A physician reviewed your appeal and determined that the plan is not required to cover the Morphine sulfate ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carbamazepine 1,000 milligrams prescribed daily for trigeminal neuralgia. The Part D Plan denied your request because the documentation did not explain why alternative drugs in a lower tier were not tried or would not work just as well. 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 you were prescribed Carbamazepine 1,000 milligrams daily for trigeminal neuralgia. The Medicare approved compendia support the use of this drug to treat your condition. However, your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them.A physician reviewed your appeal and determined that the plan is not required to cover the Carbamazepine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate mofetil 500 milligrams prescribed twice daily for amyopathic dermatomyositis. 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 Mycophenolate mofetil 500 milligrams twice daily to treat your amyopathic dermatomyositis. 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 Mycophenolate mofetil 500 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Envarsus XR, 4 milligram tablets, prescribed following a kidney transplant. The Part D plan denied your request to cover the medication 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 other information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The record shows you that your doctor prescribed Envarsus XR as an immunosuppressive drug following your kidney transplant. According to Medicare records, you were enrolled in Medicare Part A when your kidney transplant was performed on January 19, 2019. Therefore, Envarsus XR is covered under Medicare Part B. Drugs that are eligible for Part B coverage are excluded from Part D coverage by Medicare law, even if you currently do not have Part B coverage. As such, our decision is that the Part D plan is not required to cover the Envarsus XR. This decision does not refer to the medical necessity of the requested drug. It only establishes that payment cannot be made under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyzulta 0.024% drops prescribed daily at bed time for primary open-angle glaucoma. The Part D plan denied your request because the documentation did not support an non-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. You submitted a supporting statement and medical records. The medical records show you prescribed Vyzulta to treat the enrollees primary open-angle glaucoma. This is a medically accepted indication for the drug. The records indicate that the enrollee has tried Bimatoprost, Latanoprost, Dorzolamide, and Timolol. However, the records do not show why the enrollee cannot take other alternative drugs on the plans formulary for primary open-angle glaucoma.A physician reviewed your appeal and determined that the plan is not required to cover Vyzulta 0.024% drops.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metformin Hydrochloride 1,000 milligram 24 hour ER tablet prescribed daily for type 2 diabetes. 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 record shows you prescribed Metformin Hydrochloride 24 hour ER tablet to treat the enrollees type 2 diabetes. This is a medically accepted indication for the medication. Your statement indicates that the enrollee has tried Metformin ER 500 milligrams. However, the records do not show why the enrollee cannot take all other drugs on the plans formulary for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Metformin Hydrochloride 1,000 milligram ER tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a Freestyle Libre 14-day Sensor prescribed one sensor for 30 days for diabetes. The Part D plan denied the request because equipment that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. 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 your doctor prescribed a Freestyle Libre Sensor to monitor your blood sugar. However, this equipment is not covered under Medicare Part D. Medicare Part B covers medical supplies that are not directly related to the delivery of insulin to the body. The Freestyle Libre Sensor at issue is included in this category.We determined that the plan is not required to cover the Freestyle Libre Sensor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Brilinta, 90 milligrams prescribed one tablet twice daily for anti-platelet therapy. You asked the Part D plan to provide a cost-sharing tiering exception. The plan denied the appeal because there are no brand name drugs in the lower cost-sharing tiers that treat your condition. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show Brilinta is being prescribed for anti-platelet therapy. Medicare approved compendium support the use of the requested drug for your condition. Brilinta is a brand name drug on Tier 3 of your plan's formulary. There are no brand name drugs of the same type on the lower cost-sharing levels. Therefore, the requested drug is not eligible for a cost-sharing tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Brilinta because there are no brand name drugs in the lower cost-sharing tiers.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligrams prescribed daily for circadian rhythm sleep disorder, free running type. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Hetlioz 20 milligrams daily to treat your circadian rhythm sleep disorder, free running type. The Medicare approved compendia support the use of this drug to treat your condition. However, the plan requires prior authorization criteria for this drug to be met before they will cover 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 Hetlioz 20 milligrams because the plan requires prior authorization before covering some prescription drugs.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Auryxia 210 milligram tablet prescribed for hyperphosphatemia and chronic kidney disease, not on dialysis. The Part D plan denied the request for the non-eligible drug. The plan indicated the enrollee did not have a medically accepted indication for this drug. 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 Auryxia was prescribed to treat hyperphosphatemia and chronic kidney disease, not on dialysis. A prescriber statement also indicates the enrollee had tried Tums and Calcium Carbonate. However, the Medicare approved compendia does not support the use of this specific drug for the enrollees condition(s).A physician reviewed your appeal and determined that the plan is not required to cover Auryxia. 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 Ferriprox 1000 milligrams to be given twice daily for hemochromatosis due to repeated red blood cell transfusions. The Part D plan denied coverage because the prior authorization requirements 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 records submitted at the reconsideration level.Ferriprox is being requested to treat hemochromatosis due to repeated red blood cell transfusions. The plan requires the enrollee to have a diagnosis of transfusional iron overload that is due to thalassemia syndrome prior to approval of this drug. The records state the enrollees condition is not due to thalassemia syndrome. Therefore, the prior approval requirements have not been met. A physician reviewed your appeal and determined that the plan is not required to cover the Ferriprox.