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

You requested compounded preservative free dexamethasone ophthalmic drops prescribed for limbal stem cell deficiency of the right eye. The Part D plan denied your request to cover the requested compounded 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. This drug is a compounded drug. Therefore, we reviewed each ingredient individually.  The ingredients of the requested drug are: Dexamethasone Sodium Phosphate powder, Sodium Chloride granules, and Sterile Water compound.This drug is a compounded drug. Therefore, we reviewed each ingredient individually.  The ingredients of the requested drug are: Dexamethasone Sodium Phosphate powder, Sodium Chloride granules, and Sterile Water compound.  The compounded drug is not a Part D covered drug.  The components do not meet the Medicare requirements for payment under Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Sevelamer Carbonate 0.8 milligram to treat phosphate metabolism disorder. The Part D plan denied the request. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows your doctor prescribed Sevelamer Carbonate Packet to treat disorder of phosphate metabolism. This drug is being provided by the plan at the cost sharing level of Specialty Tier 5. Specialty Tier drugs are not available for a tiering exception per Medicare rules. A physician reviewed your appeal and determined that the plan is not required to cover Sevelamer Carbonate Packet because a Specialty Tier drug is not eligible for a cost-share tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine Patch 5% prescribed for neuropathy pain. 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 does not support the use of this medication for the diagnoses 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 the Lidocaine Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brilinta 60 milligram tablets prescribed twice daily for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other brand drugs on a lower cost-sharing tier. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Brilinta 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. 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: Favorable

You asked the plan to cover Nuedexta 20-10 mg capsules prescribed as directed for the treatment of pseudobulbar affect associated with Alzheimer's disease. The Part D plan denied your request because they concluded that the use of Nuedexta for treatment of pseudobulbar affect not due to multiple sclerosis or amyotrophic lateral sclerosis was not a Food and Drug Administration-approved indication or a medically accepted indication as defined by 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.The Food and Drug Administration-approved label for Nuedexta states the following: Nuedexta is indicated for the treatment of pseudobulbar affect. Pseudobulbar affect occurs secondary to a variety of otherwise unrelated neurologic conditions, and is characterized by involuntary, sudden, and frequent episodes of laughing and/or crying. Pseudobulbar affect episodes typically occur out of proportion or incongruent to the underlying emotional state. Pseudobulbar affect is a specific condition, distinct from other types of emotional lability that may occur in patients with neurological disease or injury. The Food and Drug Administration label does not limit the use of Nuedexta to PBA associated with multiple sclerosis or amyotrophic lateral sclerosis. A physician reviewed your appeal and determined that the plan is required to cover Nuedexta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% ointment prescribed three times daily for anterior chest wall pain and residual foreign body in soft tissue. The Part D plan denied your request because the prior authorization criteria has not been met, so a quantity limit exception could not be considered. 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 asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this amount of the medication including prior authorization criteria questions. We received the documentation and included it in our review.Your medical records show your doctor prescribed Lidocaine ointment to treat your condition. Your physician sent answers to the prior authorization questions. However, the records provided do not show the coverage criteria has been met; therefore, a quantity limit exception cannot be approved. A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine ointment as the prior authorization criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Epolamine 1.3% patch prescribed for spinal stenosis, lumbar. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Diclofenac Epolamine for spinal stenosis, lumbar region. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vraylar 1.5 milligram tablets prescribed for Wernicke encephalopathy. 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 Vraylar 1.5 milligram tablets to treat your Wernicke encephalopathy. 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 Vraylar 1.5 milligram tablets because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxin 550 milligram tablets prescribed three times daily for small intestinal bacterial overgrowth. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor originally prescribed Xifaxin for small intestinal bacterial overgrowth. This is an off-label use for the drug at issue. Your doctor submitted a statement indicating you have a diagnosis of irritable bowel syndrome with diarrhea; however, there were no medical records submitted to support the diagnosis change. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Depakote ER 500 milligram tablets 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

You requested Skyrizi 150 milligrams syringe prescribed as directed for pustulosis palmaris et plantaris. 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 Skyrizi to treat your condition. 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 Skyrizi because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz extra release 11 milligram tablet to treat Ankylosing spondylitis. 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

At issue is Hetlioz 20 milligram tablets to treat circadian rhythm sleep disorder and insomnia.  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.A physician reviewed your appeal and determined that the plan is not required to cover the Hetlioz. The medical records show that Hetlioz was prescribed to treat the enrollees circadian rhythm sleep disorder and insomnia. The Medicare approved compendia do support the use of this drug for circadian rhythm sleep disorder and insomnia. However, the documentation provided does not show the enrollee has satisfied the plan's coverage criteria for prior authorization.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuedexta 20-10 milligram capsules prescribed daily for pseudobulbar affect. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation does not satisfy the plans coverage criteria because a diagnosis of amyotrophic lateral sclerosis or multiple sclerosis is not documented.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 Hydrocodone polistirex/chlorpheniramine polistirex 10mg-8mg/5ml extended-release suspension prescribed as directed for a cough. 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.Drugs prescribed for the symptomatic treatment of cough and colds are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 49-51 milligram tablets prescribed two times daily for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other brand drugs on a lower cost-sharing tier. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Entresto is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gamunex-C, 10 grams per 100 milliliter vial prescribed for the treatment of inclusion body myositis. The Part D plan denied your request because the enrollees condition is not a medically accepted indication for the use of Gamunex-C. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Gamunex-C because inclusion body myositis 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 Alprazolam Extended Release one milligram prescribed for anxiety. The plan denied the appeal because this drug is not listed on your formulary plan (non-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. Your medical records show your doctor prescribed Alprazolam Extended Release for your anxiety. This drug is not listed in your plans formulary for your condition. Your doctor did not include documented medical reasons explaining why the preferred drug(s) would not work just as well. Therefore, the requested drug cannot receive a formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover Alprazolam Extended Release because the documentation does not show that you have met the coverage criteria for a formulary exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Premarin Vaginal Cream 0.625 milligrams prescribed for disorders of urinary system. The Part D plan denied your request because the Food and Drug Administration has not approved the use of this drug for the diagnosis provided. 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 Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees condition.  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 Premarin Vaginal Cream. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Votrient 200 milligram tablets prescribed four tablets daily for malignant carcinoid tumor of the bronchus and lung. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates your doctor prescribed Votrient for malignant carcinoid tumor of the bronchus and lung. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcipotriene 0.005% Cream prescribed topically for actinic keratosis. The Part D plan denied your request because the diagnosis provided did not meet the requirements of a Food and Drug Administration medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your records show your doctor prescribed Calcipotriene 0.005% Cream to treat your actinic keratosis. However, the Medicare approved compendium does not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Calcipotriene 0.005% Cream because your diagnosis does not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine patch 1.3% to treat other tear of medial meniscus, current injury, unspecified knee, initial encounter, pain in unspecified knee, and stiffness of right elbow, not elsewhere classified. 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.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 Xifaxan 550 milligram tablets to treat other specified diseases of intestines.  The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization requirements be met 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 information submitted at the reconsideration level.A physician reviewed your appeal and determined that the plan is not required to cover the Xifaxan. The medical records show that Xifaxan was prescribed to treat the enrollees condition. The Medicare approved compendia does support the use of this drug for irritable bowel syndrome. However, the documentation provided does not show the enrollee has satisfied the plan's coverage criteria for prior authorization.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol Sulfate 2.5 milligrams per 3 milliliters vial prescribed for chronic obstructive pulmonary disease. The Part D plan auto-forwarded this case.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 doctor prescribed Albuterol Sulfate for chronic obstructive pulmonary disease. However, this drug is eligible for coverage under Medicare Part B. Medicare Part B covers this drug, when used with a nebulizer in the home. Medicare Part D cannot pay for drugs that are covered by Medicare Part B.We determined that the plan is not required to cover Albuterol Sulfate.