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

At issue is Theophylline ER 300 milligram tablets prescribed twice daily for chronic obstructive pulmonary disease, chronic shortness of breath, and chronic respiratory failure. The Part D plan denied your request for a tiering exception. 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. Theophylline ER is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated that you have tried all alternatives required by the plan, or why the plans lower tiered drugs would likely not be as effective as the requested drug. 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 requested Adderall XR 20 milligram capsule to treat attention deficit disorder. The Part D plan denied your request due to safety concerns with your taking Adderall XR 20 mg with another drug you are taking, Clonazepam.  We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were initially approved for a formulary exception for Adderall XR 20 milligram capsule for the 2021 plan year. However, the Part D plan noted safety concerns.  Adderall XR has a potential interaction with Clonazepam 0.5 milligram tablet. The prescriber sent a letter dated 3/15/2021 addressing your medical history and the safety concerns.  The prescriber stated that you also have the diagnosis of insomnia and anxiety and have been stabilized with Clonazepam.  The prescriber went on to state that, Although there are potential interactions between these two drugs, Zachary has taken them safely and successfully for years now.  He does not take them concurrently.  Zacharys attention deficit hyperactivity disorder has been stabilized on Adderall XR and Adderall.  His anxiety and insomnia have been stabilized with clonazepam.  The prescriber has stated why the enrollee needs both drugs.  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 Lyrica 150 milligram tablets for lumbago and sciatica. 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 Lyrica was prescribed for lumbago and sciatica. The Medicare approved compendia do not support the use of this drug for the enrollees 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 Lyrica.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Forteo 600 microgram/2.4 milliliter Solution Pen Injector prescribed for postmenopausal female with osteoporosis. 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 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 prescriber did not submit information on if there was a risk of osteosarcoma in the enrollee. Additionally, medical records were not submitted. Therefore, the prior authorization requirements were not met.   A physician reviewed your appeal and determined that the plan is not required to cover Forteo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Orgovyx 1 milligram to treat prostate cancer. The Part D plan denied the request.  The requested drug is not on the plans formulary. 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 medical records do not address why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate Hydrochloride ER 10 milligram capsules prescribed two times daily to treat to treat hypersomnia, unspecified, and obstructive sleep apnea. The Part D plan denied the request for a formulary exception, 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 diagnoses 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 these conditions.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine 10 milligrams prescribed as directed for sciatica, degeneration of cervical intervertebral disc, lumbar radiculopathy, and lumbar spinal stenosis. The Part D plan denied the request because it does not meet the criteria of a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The record shows you were prescribed Cyclobenzaprine 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 Cyclobenzaprine because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone hydrochloride ER 15 milligram tablets prescribed as directed for pain. 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 physician states the enrollee is taking Oxycodone hydrochloride ER for pain related to thoracolumbar spinal fusion, post laminectomy syndrome, and chronic pain syndrome. However, the records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover Oxycodone hydrochloride ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Contour Next diabetic test strips. The Part D plan denied the request because glucose monitoring supplies are covered under Medicare Part B. 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 glucose monitoring supplies at issue were ordered for your diabetes mellitus. Glucose monitoring supplies are covered by Medicare Part B and are not considered a Part D benefit.We determined that the plan is not required to cover the Contour Next test strips.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60 milligram injection prescribed as directed for postmenopausal osteoporosis. The Part D plan denied coverage because 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. Your medical records show you were prescribed Prolia for your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided does not show the coverage criteria has been met. 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 Prolia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nubeqa 300 milligram tablet prescribed for metastatic prostate cancer. 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 reviewed your appeal carefully. We reviewed all documentation available.The plan requires that prior authorization criteria be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Nubequa 300 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metformin Hydrochloride (MOD) ER 1000 milligram tablets. The Part D plan denied coverage because the plans prior authorization requirements were not met. We received a reconsideration request.We received the case to perform 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 Metformin Hydrochloride (MOD) ER has been prescribed to treat the enrollees type 2 diabetes mellitus. However, the prescriber has not indicated that the enrollee experienced an intolerance to generic Glucophage XR, which is required by the plan. 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 Metformin Hydrochloride (MOD) ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine 2 milligram sublingual tablet to be given three times daily as needed for lumbosacral spondylosis. 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 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 records submitted at the reconsideration level.Buprenorphine 2 milligram sublingual tablet is being requested to treat back pain due to lumbosacral spondylosis. The Medicare approved compendia do not support the use of this drug formulation for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover the Buprenorphine 2 milligram sublingual tablet.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Esbriet 267 milligram capsules prescribed for idiopathic pulmonary fibrosis. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation availableThe enrollee satisfies the plan's coverage criteria. The documentation supports a diagnosis of idiopathic pulmonary fibrosis. A high resolution computed tomography scan confirms usual interstitial pneumonia.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Methylphenidate Hydrochloride 5 milligram tablets prescribed daily for refractory depression. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Methylphenidate Hydrochloride for refractory depression.In review of the Medicare approved compendia, refractory depression is not a medically accepted indication for Methylphenidate Hydrochloride. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Methylphenidate Hydrochloride at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tizanidine Hydrochloride 4 milligram tablet prescribed for muscle spasms. The plan denied the appeal because this drug is not listed on your formulary plan (non-formulary) and formulary alternatives had not been tried. 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 Tizanidine Hydrochloride for your muscle spasms. This drug is not listed in your plans formulary. Your doctor did not indicate that you tried the alternative drugs listed on your plans formulary for your condition, why they did not work, or they caused adverse effects. Therefore, the requested drug cannot receive a formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover Tizanidine Hydrochloride 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 Lidocaine 5 percent ointment to treat chronic shoulder pain and weakness. The Part D plan denied your request because the provided diagnoses do 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. 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 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 ointment because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Firdapse 10 milligram tablets prescribed as directed for Lambert-Eaton myasthenic syndrome. The Part D plan denied coverage because the prior authorization criteria were not met. The Part D plan also stated the drug is only available as a recurring 30-day supply if coverage is approved. 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 shows the physician prescribed Firdapse to treat an enrollee with Lambert-Eaton myasthenic syndrome. The drug is requested for a medically accepted indication. Prior Authorization criteria however were not satisfied. However, the prescriber correctly indicates that the alternative drug required (Ruzurgi) in the prior authorization criteria, is FDA approved only in the population less than 17 years old, this patient is 76 years old (Micromedex). This is reinforced in the dosing information for Amifampridine (Firdapse and Ruzurgi), showing only a Firdapse adult dosing schedule. The pharmacokinetic profile of these 2 drugs is also different. Therefore an exception to the prior authorization is granted.A physician reviewed your appeal and determined that the plan is required to cover Firdapse.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Olanzapine 5 milligram tablets prescribed twice daily for depression with psychosis/hallucination and generalized anxiety disorder. 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 Olanzapine for depression with psychosis/hallucination and generalized anxiety disorder. 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: Favorable

You requested Potassium chloride 20 milliequivalent tablets prescribed for you in the hospital. The Part D plan approved coverage for the drug. We received an auto-forwarded request from the plan to reconsider the appeal. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted.The record shows you received the drug under observation for medical care at the hospital. You submitted documentation to the plan that includes a copy of an itemized hospital bill. The documentation provided indicates the plan approved payment for the Potassium chloride  Therefore, we determined that the plan is required to reimburse you. The plan calculates reimbursement based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the out-of-network pharmacy (i.e., hospital) charged you.
Appeal type: Prescription Drug
Decision: Favorable

You requested Spironolactone 25 milligram tablets prescribed for you in the hospital. The Part D plan approved coverage for the drug. We received an auto-forwarded request from the plan to reconsider the appeal. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted.The record shows you received the drug under observation for medical care at the hospital. You submitted documentation to the plan that includes a copy of an itemized hospital bill. The documentation provided indicates the plan approved payment for the Spironolactone. Therefore, we determined that the plan is required to reimburse you. The plan calculates reimbursement based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the out-of-network pharmacy (i.e., hospital) charged you.
Appeal type: Prescription Drug
Decision: Favorable

You requested Hydrocodone acetaminophen 5-325 milligram tablets prescribed for you in the hospital. The Part D plan approved coverage for the drug. We received an auto-forwarded request from the plan to reconsider the appeal. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted.The record shows you received the drug under observation for medical care at the hospital. You submitted documentation to the plan that includes a copy of an itemized hospital bill. The documentation provided indicates the plan approved payment for the Hydrocodone acetaminophen. Therefore, we determined that the plan is required to reimburse you. The plan calculates reimbursement based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the out-of-network pharmacy (i.e., hospital) charged you.
Appeal type: Prescription Drug
Decision: Favorable

You requested Saphris 5 milligram tablets prescribed for you in the hospital. The Part D plan approved coverage for the drug. We received an auto-forwarded request from the plan to reconsider the appeal. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted.The record shows you received the drug under observation for medical care at the hospital. You submitted documentation to the plan that includes a copy of an itemized hospital bill. The documentation provided indicates the plan approved payment for the Saphris. Therefore, we determined that the plan is required to reimburse you. The plan calculates reimbursement based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the out-of-network pharmacy (i.e., hospital) charged you.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Upneeq. The Part D plan denied the request as an excluded drug in the Medicare Part D program. 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.Upneeq is an FDA approved drug with National Drug Codes and is a medically accepted indication for the enrollee's condition of ptosis of eyelid. It is non-formulary for the plan. There are no formulary drugs to treat the condition.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage