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

At issue is Donepezil 23 milligrams prescribed for mild cognitive impairment. 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. The documentation includes a support statement from the physician. Donepezil was prescribed to treat mild cognitive impairment. However, the records do not show why the enrollee cannot take all drugs on the plans formulary for mild cognitive impairment. The physician did not indicate all alternatives to treat the condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Donepezil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Forteo 20 microgram/dose pen injector to treat osteoporosis.   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.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan would likely cause harm or not be as effective as the requested drug.  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 Enbrel 50 milligrams/milliliter syringes prescribed weekly for rheumatoid arthritis. 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.Enbrel 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 Armour Thyroid 90 milligram oral tablet to treat hypothyroidism.   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.Non-FDA approved drugs are excluded from Medicare Part D coverage.  Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil Citrate 20 milligram tablet prescribed daily for erectile dysfunction. The plan denied the request because the information provided did not meet the requirements for coverage. 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 Sildenafil Citrate 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 Citrate because the drug is excluded from the Medicare Part D benefit for your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pregabalin 75 milligram oral capsule prescribed daily for bilateral leg pain. The Part D plan denied your request because 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 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 Pregabalin was prescribed to treat your bilateral leg pain, primarily right leg pain secondary to surgery for hardware migration and bilateral foraminotomies with a lo-flex procedure. However, the Medicare approved compendia do not support the use of this drug for this condition. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.A physician reviewed your appeal and determined that the plan is not required to cover Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diphenhydramine 50 milligrams per milliliter vial to treat headache pain due to chronic migraine. 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.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Viagra 100 milligram tablets prescribed as directed for erectile dysfunction. The Part D plan denied your request because drugs being used for the treatment of erectile dysfunction are excluded from coverage by Medicare 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 Viagra. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methocarbamol. 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.No medical records were provided by the prescriber. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. 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 Methocarbamol because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyanocobalamin 1000 micrograms/milliliter prescribed intramuscular once weekly for seizures. The Part D plan denied the appeal because the drug is excluded under the Medicare Part D benefit. There are no conditions under which this request would be approved under Medicare 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. Your record shows that your doctor prescribed Cyanocobalamin for your seizures. Cyanocobalamin is excluded from coverage under the Medicare Part D benefit because the drug does not meet the definition of a Part D drug. This is not to say that this drug does not benefit you, just that Medicare does not allow this drug for any condition under the Medicare Part D benefit. We have determined that your plan is not required to cover Cyanocobalamin because the drug does not meet the definition of a Part D drug under Medicare law.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablets to treat your condition(s). 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 your condition(s). Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Tadalafil 5 milligram tablets. The Part D plan denied the request because the plans prior authorization requirements for the use of Tadalafil in the treatment of benign prostatic hyperplasia were not met. Additionally, drugs used solely to treat erectile dysfunction are not covered under Medicare Part D. 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 submitted prescriber statement indicates that the Tadalafil is being used to treat both benign prostatic hyperplasia with lower urinary tract symptoms and erectile dysfunction. However, the Part D plan prior authorization requirements for coverage of Tadalafil in the treatment of benign prostatic hyperplasia have not been satisfied. Additionally, it should be noted that Medicare has excluded Part D coverage of drugs when being used specifically to treat erectile dysfunction.A physician reviewed the appeal and determined that the Tadalafil is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Repatha Sureclick Auto Injector 140 milligrams/milliliter to treat mixed hyperlipidemia. The Part D Plan denied the request because the information received from your prescriber does not support approval because you have not met your plan's prior authorization requirements. 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 medical records show your doctor prescribed Repatha Sureclick Auto Injector to treat your mixed hyperlipidemia. The Medicare approved compendium supports the use of Repatha for your condition when prior authorization criteria are met.  Additional information was received at this level of appeal but it did not satisfy prior authorization criteria.A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick Auto Injector because the plan's prior authorization criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil Citrate 25 milligrams prescribed three times daily for primary pulmonary hypertension. 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 medical records show your doctor prescribed Sildenafil Citrate 25 milligrams three times a day to treat your condition. However, the Medicare approved compendia do not support the use of this drug, as prescribed, for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Sildenafil Citrate 25 milligrams three times a day.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sucraid 8500 units/milliliter prescribed for congenital sucrase-isomaltase deficiency. 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. The documentation supports the drug was prescribed for the enrollees diagnosis. The plan requires a diagnosis of congenital sucrase-isomaltase deficiency and the diagnosis was confirmed by a small bowel biopsy or genetic testing. 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 Sucraid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Forteo 600 micrograms per 2.4-milliliter injection prescribed daily for severe osteoporosis. The Part D plan denied your request for a tier change request because Forteo 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 Forteo is being prescribed for severe osteoporosis. The Medicare approved compendia, supports the use of the requested drug for your condition. This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a tiering exception request for Desvenlafaxine succinate 50 milligram tablet 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.Desvenlafaxine succinate is a generic drug on Tier 3 of the plans formulary. The prescriber has indicated the alternatives you have tried as required by the plan. The prescriber statement indicates amitriptyline was included in previously trialed medications with adverse effects and/or failure to respond.  The medications not specifically named in the prescriber statement as tried and failed and on the plan formulary are tricyclic antidepressants in the same class as amitriptyline.  Our physician reviewer's opinion is that tiering exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lubiprostone 24 microgram capsule prescribed twice daily for irritable bowel syndrome with constipation. The Part D plan denied your request because the documentation did not support your diagnosis was a medically accepted indication. Also, the drug is not listed on your 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. Medicare approved compendia supports the use of the requested drug for your condition. However, the records do not show why you cannot take other drugs on your plans formulary for your condition.A physician reviewed your appeal and determined that the plan is not required to cover Lubiprostone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Evenity 210 milligram syringe prescribed for age-related osteoporosis. 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. Your physician submitted a supporting statement. The supporting statement did not indicate formulary alternatives would be ineffective. The records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover Evenity.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Procrit 10,000 units per milliliter with 40,000 units to be given subcutaneously for unspecified anemia. 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 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 records submitted at the reconsideration level.Procrit is being requested to treat anemia most consistent with myelodysplastic syndrome. The diagnosis of myelodysplatic syndrome is not confirmed. 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 the Procrit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tacrolimus 1milligram capsule prescribed for kidney transplant. The Part D plan denied the request because you were eligible for Medicare Part B coverage at the time of transplant. 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. Medicare records indicate you received a kidney transplant on December 1, 2020, which was covered by Medicare Part A. Therefore, Tacrolimus is eligible under Medicare Part B. We determined that the plan is not required to cover the Tacrolimus. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lyrica 75 milligrams prescribed daily for trigeminal neuralgia. The Part D plan denied your request because the provided diagnosis 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 Lyrica 75 milligrams to treat your trigeminal neuralgia. 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 Lyrica 75 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Sodium 360 milligram prescribed one tablet three times a day for post-kidney transplant. The Part D plan was unable to make a timely decision. We received an auto-forwarded reconsideration request from the plan.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. We determined that the drug is eligible for Part B coverage. The beneficiary had a Medicare-covered transplant on December 1, 2020. Therefore, the drug can be considered for payment under the Part B benefit.A physician reviewed your appeal and determined that the plan is not required to cover.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Mometasone 50 microgram nasal spray prescribed for nasal polyps. 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 Mometasone to treat your nasal polyps. The Medicare approved compendia support the use of this drug for your condition. Your doctor submitted a prescriber statement indicating that you tried Flonase, Nasacort, Rhinocort, and fluticasone nasal inhalers. These drugs 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.