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

At issue is Imvexxy Maintenance Pack Insert 10 micrograms prescribed for vaginal atrophy and recurrent urinary tract infections. 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.  Medicare approved compendia do support the use of this medication for the diagnoses submitted. Therefore, it is considered a medically accepted indication. However, the plan has prior authorization coverage criteria that are not satisfied by the records provided. Therefore, coverage cannot be provided.  A physician reviewed your appeal and determined that the plan is not required to cover Imvexxy Maintenance Pack Insert.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 10 milligram capsules prescribed daily for chronic nausea/vomiting associated with massive malignant cystic disease of the liver. The Part D plan denied your request because 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 prescriber statement shows Dronabinol was prescribed to treat the enrollees chronic nausea/vomiting due to massive malignant cystic disease of the liver with associated severe protein/calorie deficiency malnutrition. 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate Hydrochloride 20 milligram tablets prescribed for the diagnosis of bipolar affective disorder. 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. Medicare approved compendia do not support the use of this medication for the diagnosis submitted. Therefore, it is ineligible for coverage under Medicare Part D.   A physician reviewed your appeal and determined that the plan is not required to cover Methylphenidate Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tymlos, 3120 micrograms/1.5 milliliter solution, pen injector prescribed every 30 days subcutaneously for postmenopausal osteoporosis. Your Part D plan denied the drug because the prior authorization criteria was 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 your prescriber to send us information regarding your condition. We also asked for medical records, a DXA scan, and other documentation to show why you need this medication. Additional documentation was not received.Your medical records show your doctor prescribed Tymlos to treat your postmenopausal osteoporosis. The Medicare approved compendium does support the use of Tymlos for your condition. However, the prior authorization does not show that you have met the conditions of coverage. A physician reviewed your appeal and determined that the plan is not required to cover Tymlos because the conditions of coverage have not been met per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis tablet, 5 milligrams prescribed to treat your 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.Our Physician Reviewer's opinion is that the tiering exception criteria have not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo 4 milligram tablets prescribed daily for diabetes and vascular disease. 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. Livalo is a generic 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 Livalo.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Genadur (Biotin) Oral Solution to treat vitamin or mineral deficiencies. 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. Drugs prescribed for use as vitamin and mineral products are excluded from coverage under the Medicare Part D benefit. This is not to say that Genadur Oral Solution does not benefit you, just that Medicare has excluded it from coverage under the Medicare Part D benefit. Therefore, the requested drug is excluded from coverage.We have determined that your plan is not required to cover Genadur Oral Solution because it is considered a vitamin and mineral product and is excluded from coverage under the Medicare Part D benefit per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armodafinil 150 milligram tablets prescribed for the diagnosis of attention deficit hyperactivity disorder. 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 physician originally stated the enrollee had attention deficit hyperactivity disorder and has submitted another statement indicating that the enrollee suffers from shift work disorder. We submitted a request to the prescriber to verify the diagnosis and to submit medical records supporting the diagnosis. The prescriber did not respond. Medicare approved compendia does not support the use of this medication for the diagnosis submitted of attention deficit hyperactivity disorder and the documentation was insufficient to support another diagnosis. Therefore, the drug is ineligible for coverage under Medicare Part D.   A physician reviewed your appeal and determined that the plan is not required to cover Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix vaccine for the prevention of herpes zoster (shingles). 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 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. Shingrix vaccine is a biologic drug on Tier 3 of the plans formulary. There are no biologic 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. Our Physician Reviewers opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligrams/2 milliliters prescribed 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 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 do not show why the enrollee cannot take other drugs on the plans formulary for their condition. There are multiple drugs listed in the formulary that the prescriber did not address. A request was sent to the prescriber for additional information but we did not receive any additional records. A physician reviewed your appeal and determined that the plan is not required to cover Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% topical patches prescribed to treat your chronic pain related to rheumatoid arthritis and fibromyalgia. 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 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. A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine patches. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carbamazepine ER, 100 milligram tablets prescribed for your facial paresthesia (paresthesia of the skin). The Part D plan denied your request because you do not have a covered condition. We received an expedited auto-forwarded request from the coverage level to reconsider the appeal. 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 Carbamazepine ER because paresthesia of the skin is not a medically accepted indication to use this drug.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

You requested Lidocaine 5 percent patch prescribed as needed for cervical disc disorder with radiculopathy. The Part D plan denied your request because it 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 Lidocaine 5 percent patch as needed to treat your cervical disc disorder with radiculopathy. 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 Lidocaine 5 percent patch because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hysingla ER, 20 milligram tablets prescribed for chronic pain syndrome. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Hysingla ER as an off-formulary exception.The submitted documentation shows that the drug was prescribed to treat your chronic pain syndrome. The Medicare approved compendia support the use of the requested drug for this condition. However, the submitted documentation does not include medical records that sufficiently address why all of the alternative drugs listed in the plans formulary to treat chronic pain syndrome have not been tried, or are contraindicated. Therefore, the plan will not cover the Hysingla ER as an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Apokyn 30 milligrams per 3 milliliters, solution cartridge prescribed to treat wearing off symptoms of Parkinsons disease. The Part D plan denied your request for a tier 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 the requested drug was being prescribed to treat the provided diagnosis. Apokyn 30 milligrams per 3 milliliters, solution cartridge is a brand name on Tier 5 of the plans formulary. There are no generic or brand drugs of the same type available on the lower cost-sharing tier to treat the enrollees condition. The plan cannot approve a tier exception for drugs on Tier 5. We have determined that the plan is not required to provide a tiering exception.A physician reviewed your appeal and determined that the requested drug is not eligible for coverage under Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Adderall XR 30 milligram tablets prescribed for attention deficit hyperactivity disorder. The Part D plan denied your request for a formulary exception. We received an expedited 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 Adderall XR to treat attention deficit hyperactivity disorder. The Medicare approved compendia supports the use of this drug for your condition. Your doctor submitted a prescriber statement indicating that you tried regular release Adderall. This drug did not improve your condition. However, the plan formulary includes other drugs that could be used to treat your condition. Your records do not show that all alternative drugs on the plan formulary have been tried or why you cannot take them. This decision does not address the medical necessity of the requested drug. It only means that it cannot grant a formulary exception for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil 250 milligrams prescribed daily for autoimmune ataxia due to GAD65 antibody. The Part D plan denied your request because it 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 Mycophenolate Mofetil 250 milligrams daily to treat your autoimmune ataxia due to GAD65 antibody. 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 250 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Moxifloxacin HCL 400 milligrams prescribed as directed to prevent the formation of liver abscesses due to malignant neoplasm of the liver and pancreas. The Part D plan denied the request because it does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The record shows you were prescribed Moxifloxacin HCL to prevent the formation of liver abscesses due to malignant neoplasm of the liver and pancreas 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 Moxifloxacin HCL because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Zarontin 250 milligram capsules to treat your epilepsy. 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 Entresto 24mg-26 milligram tablet to treat coronary artery disease in an enrollee with a history of myocardial infarction. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Urogesic-Blue for the enrollees condition. The Part D plan denied your request because the drug at issue was not Food and Drug Administration approved. 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 your physician prescribed Urogesic-Blue. The drug at issue is not Food and Drug Administration approved. Therefore, the drug cannot be considered a Part D benefit.We determined that the plan is not required to cover the Urogesic-Blue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide 1 milligram per 2-milliliter inhalation suspension to treat chronic bronchitis in an enrollee with pulmonary sarcoidosis. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Eliquis 5 milligrams prescribed daily for the enrollees condition. The Part D plan denied your request because Eliquis is a brand name Tier 3 drug and the lower cost-sharing tiers only contain generic alternative 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. In this instance, the plan shows Eliquis is a brand name Tier 3 drug. 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 tiering exception.