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 Medicare Prescription Drug Benefit Manual, Chapter 6, 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. Also, medically accepted indication refers to the diagnosis or condition for which a drug is being prescribed, not the dose being prescribed for such indication. Part D sponsors may have dose limitations based on Food and Drug Administration labeling, but an enrollee may request (and be granted) an exception to a dose restriction through the formulary exception process based on medical necessity criteria.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; the Centers for Medicare & Medicaid Services Internet-Only Manual, Publication 100-18, Medicare Prescription Drug Benefit Manual, Chapter 6, Section 10.6]
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 100 milligram tablet prescribed daily for erectile dysfunction. The plan denied the request because Medicare has excluded Part D coverage of drugs when being used specifically for the treatment of erectile dysfunction. 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 records show your doctor prescribed Sildenafil to treat your erectile dysfunction. However, Medicare excludes this drug from the Medicare Part D benefit to treat your condition. As such, the prior authorization requirements of a medically accepted indication for this drug have not been met.A physician reviewed your appeal and determined that the plan is not required to cover Sildenafil because the drug is excluded from coverage by the Medicare Part D benefit for your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nitazoxanide 500 milligram tablet prescribed four-times-daily for irritable bowel syndrome with diarrhea. The Part D plan denied your request stating that the quantity limit exception cannot be made because the diagnosis provided does not meet the requirements of a Food and Drug Administration 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 your doctor prescribed Nitazoxanide to treat your irritable bowel syndrome with diarrhea. However, the Medicare approved compendium does not support the use of this drug for your condition. As such, a quantity limit exception cannot be made.A physician reviewed your appeal and determined that the plan is not required to cover Nitazoxanide because your diagnosis does not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a formulary exception for Evrysdi Solution 0.75 milligram/milliliter prescribed for spinal muscular atrophy. The Part D plan denied your request. 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 physician submitted laboratory studies and the weight of the enrollee. Medicare approved compendium supports the use of the requested drug for this condition. The physician states there are no other drugs on the plans formulary to treat this condition.The plans formulary does not contain other drugs to treat this condition and the drug is approved by the food and drug administration to treat this disorder.  A physician reviewed your appeal and determined that the plan is required to cover Evrysdi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyzulta 0.024% ophthalmic solution prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception. 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.Vyzulta 0.024% ophthalmic solution is a non-formulary drug. Non-formulary drugs 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 Ensure liquid for the treatment of anorexia. The plan denied the request because Medicare excludes over-the-counter drugs from Part D coverage. 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.According to Medicare rules, drugs that can be purchased over-the-counter are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover Ensure liquid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ipratropium-Albuterol 0.5 milligram-3 milligram/3milliliter ampule via nebulization for the treatment of asthma and chronic obstructive pulmonary disease.  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 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. We also researched Medicare systems and reviewed the enrollment data available.Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Contour next test strips prescribed to the enrollee for the treatment of diabetes. The plan denied the request because coverage for blood glucose testing supplies are excluded from coverage under Part D.  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 determined that the plan is not required to cover the Contour next test strips because they are not considered a medical supply directly associated with the injection of insulin. Although, this drug is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. 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

At issue is Dupixent 300 milligram\2 milliliter injection prescribed as directed to treat moderate to severe atopic dermatitis. 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 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 Dupixent to treat your condition. There are no medical records to support 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 Dupixent because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablet prescribed for hepatic encephalopathy prophylaxis. 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 medical records show you prescribed Xifaxan 550 milligram tablet to treat the enrollees cirrhosis. Your statement indicates that Xifaxan is being used for hepatic encephalopathy prophylaxis. The Medicare approved compendia support the use of Xifaxan 550 milligram tablet for reduction in risk of overt hepatic encephalopathy recurrence in adults. The medical records submitted do not support at least one episode of overt hepatic encephalopathy. Therefore, the records submitted do not support a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Xifaxan 550 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acitretin 25 milligram capsules. The Part D plan denied coverage because the plans 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 requested and submitted at the reconsideration level. The documentation shows that Acitretin has been prescribed to treat the enrollees psoriasis. However, the prescriber has not indicated that the enrollee has experienced an inadequate treatment response, intolerance, or contraindication to methotrexate or cyclosporine, which is a requirement for coverage of the drug. Therefore, the plans prior authorization requirement has not been satisfied. A physician reviewed your appeal and determined that the plan is not required to cover the Acitretin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsules prescribed for circadian rhythm sleep disorder (non-24), and blindness. 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 records submitted at the reconsideration level. We asked the prescriber to send us information regarding the enrollees condition. We received the documentation and included it in our review.The prescriber statement states that the enrollee is discontinued from medication. Therefore, the documentation does not satisfy the plans coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsules prescribed for circadian rhythm sleep disorder. The Part D plan denied the request. We received a standard 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 regulations and Medicare approved compendia. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the diagnosis, and the plans coverage criteria, and/or the coverage criteria are not satisfied by the provided medical records.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.   A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligrams prescribed one tablet twice a day for hepatic encephalopathy. The Part D plan denied your request for a tiering exception because the drug at issue is on a Specialty tier and is not eligible for a lower cost-sharing tier. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Xifaxan is on the Specialty tier of your plans formulary. Drugs that are on the plans Specialty tier are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xolair 150 milligram/milliliter solution prescribed for the enrollees allergic asthma. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level. The documentation supports the drug was prescribed for the enrollees diagnosis of allergic asthma. However, the enrollee does not satisfy the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vascepa capsules to treat reduction of triglycerides. The Part D plan denied your request for a tiering exception. 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 Vascepa capsules is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers for the enrollees 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 grant a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hysingla 40 milligram extended-release oral tablet prescribed daily for bilateral lumbar radiculopathy and chronic pain disorder. The Part D plan denied your request for a tiering 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. Hysingla is a brand drug on Tier 3 of the plans formulary. Your doctor submitted a supporting statement. The statement said you could not tolerate Tramadol, Hydrocodone, Cymbalta, Cyclobenzaprine, Zamaflex, and Diclofenic. However, your doctor did not address why the alternative medications on the lower cost sharing tier would not work for you. All brand 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 Synthroid 75 microgram oral tablet. The Part D plan denied your request for a tiering 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. Synthroid is a brand drug that is not on the plans formulary. Medicare has already granted a formulary exception for the drug. A tiering exception cannot be allowed for a drug that is not on 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 Synthroid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin 80 milligram ER tablets. The Part D plan denied your request. 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. You are requesting a direct member reimbursement for the drug at issue. Your physician did not submit a supporting statement. A request was made for a supporting statement and medical records. The submitted documentation does not support a prescribed diagnosis for the drug at issue. It cannot be determined if the drug at issue was prescribed for a medically accepted indication. Therefore, the drug cannot be reimbursed by the plan.A physician reviewed your appeal and determined that the plan is not required to reimburse Oxycontin ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate extended-release oral tablet prescribed for depression. The Part D plan denied your request. 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.The physicians supporting statement shows Methylphenidate was prescribed to treat depression. 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 Methylphenidate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Spiriva Handihaler 18 micrograms 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.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxyzine Hydrochloride 25 milligrams prescribed one tablet every eight hours as needed for anxiety. 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. The documentation supports the drug was prescribed for the enrollees diagnosis of anxiety. However, the enrollee does not satisfy the plan's prior authorization coverage criteria. The documentation does not support the physician tried at least two other approved drugs to manage your anxiety as well as documented the assessment of the risks versus benefits in prescribing this drug.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexletol 180 milligram tablets to treat hypercholesterolemia. The Part D plan denied coverage because there was insufficient documentation to support that the prior authorization criteria were met. 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 records submitted at the reconsideration level. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. A physician reviewed your appeal and determined that the plan is not required to cover Nexletol.