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

You requested Synvisc 16 milligram intra-articular injection prescribed as directed for osteoarthritis of the right knee. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received 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 physician administered Synvisc intra-articular injection for an enrollee with osteoarthritis of the right knee. However, this drug is eligible for coverage under Medicare Part B because it is furnished incident to a physicians service. We determined that the plan is not required to cover Synvisc.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cefdinir 300 milligrams. 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 that confirm a diagnosis. 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 Cefdinir because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is the Diflucan 150 milligrams. 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 that confirm a diagnosis. 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 Diflucan because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hysingla ER 30 milligram tablets prescribed for to lumbar radiculopathy. 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 documentation does not show a medical reason 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 the drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Armodafinil, 150 milligram tablets prescribed for excessive daytime sleepiness associated with obstructive sleep apnea. The Part D plan denied coverage because there was not confirmation that the diagnosis was confirmed by a sleep lab evaluation. 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 submitted medical records and prescriber statement indicate that the enrollee has been using Armodafinil for excessive daytime sleepiness associated with obstructive sleep apnea since March 2015. The Medicare approved compendia do support the use of the drug for this condition. The Part D drug plan requires that when Armodafinil is prescribed to improve wakefulness in adult members with excessive sleepiness associated with obstructive sleep apnea, the diagnosis of obstructive sleep apnea must be confirmed by a sleep lab evaluation. The documentation provided by the physician at reconsideration includes results from a sleep lab evaluation which does confirm that the enrollee has obstructive sleep apnea. Therefore, the medical records support that the plans prior authorization requirement has been satisfied.A physician reviewed your appeal and determined that the plan is required to cover the Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Orgovyx 120 milligram tablet prescribed as directed to treat prostate cancer. 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The record shows that your doctor prescribed the Orgovyx to treat your condition. Your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Orgovyx because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligrams one tab twice a day prescribed for hepatic encephalopathy. The Part D plan denied your request for a tiering exception and 90 day supply because the drug you requested is in the specialty tier; drugs placed in the specialty tier are not eligible for tiering exceptions or 90 day supplies. 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. Xifaxan is a brand drug on Tier 5, also known as the Specialty Tier, of the plans formulary. If a plan maintains a Specialty Tier, the plan may design its exception process so that drugs placed in the Specialty Tier are not eligible for a tiering exception or 90 day supplies. The record indicates the plan has chosen to exclude the Specialty Tier from the tiering exception process and 90 day supplies. Therefore, this drug is not eligible for a tiering exception or a 90 day supply.A physician reviewed your appeal and determined that the plan is not required to cover Xifaxan. This drug is being provided by your plan at the cost sharing level of the Specialty Tier. Specialty Tier drugs are not available for a tiering exception per Medicare rules. The plan has also denied 90 day supplies for drugs on their Specialty Tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tizanidine Hydrochloride 4 milligrams prescribed for cervical spondylosis. 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 prescriber has not indicated why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans 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 Nucynta 50 milligram tablets to chronic pain.  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 Megestrol Acetate. 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 record shows enrollee has weakness, diarrhea, poor appetite, and weight loss. The physician prescribed Megestrol Acetate. 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.   A physician reviewed your appeal and determined that the plan is not required to cover Megestrol Acetate.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Methylphenidate Hydrochloride 20 milligram tablets prescribed for the diagnosis of attention deficit disorder (ADD). We received an expedited reconsideration request. We performed and independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation submitted. Medicare approved compendia does supports the use of this medication for the diagnosis submitted. In the current nomenclature, ADHD, inattentive type replaces what was previously named attention deficit disorder. Therefore, Methylphenidate is eligible for coverage under Medicare Part D as ADD is included in the medically accepted indication of ADHD.   A physician reviewed your appeal and determined that the plan is required to cover Methylphenidate Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Slynd 4 milligram tablets prescribe to treat pelvic and perineal pain and unspecified cyst of the right ovary. 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The Medicare approved compendia do not support the use of this drug for the reported diagnoses. Medicare requires that the drug must be prescribed for a medically accepted indication that is approved by the FDA or supported by one or more citations in Medicare approved compendia.Our Physician Reviewer determined that the plan is not required to cover Slynd.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amphetamine-Dextroamphet Extended Release 10 milligram capsule prescribed for binge eating disorder. The Part D plan denied your request because the diagnosis provided does not meet the requirements of a Food and Drug Administration medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your medical records show your doctor prescribed Amphetamine-Dextroamphet Extended Release to treat your binge eating disorder, which is an off-label use. The Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Amphetamine-Dextroamphet Extended Release because your diagnosis does not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Favorable

You requested Methylphenidate Hydrochloride 20 milligram extended-release tablets prescribed daily for attention deficit hyperactivity disorder. 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 prescriber initially provided the diagnosis of personal history of mental behavioral disorder. In the request for reconsideration, the prescriber statement shows the enrollee was diagnosed with attention deficit hyperactivity disorder. Recent medical records dated February 25, 2021, were provided that document the requested drug is being used for the treatment of attention deficit hyperactivity disorder. The Medicare approved compendia supports the use of this drug for this condition. The requested drug, as prescribed, meets the definition of a Medicare Part D drug. A physician reviewed your appeal and determined that the plan is required to cover Methylphenidate Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Abilify 10 milligram tablets prescribed daily for bipolar I disorder. The Part D plan denied your request for a tiering exception. 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. The requested drug is being provided by your plan under a formulary exception. Abilify 10 milligram tablets are 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. A physician reviewed your appeal and determined that the plan is not required to cover Abilify 10 milligram tablets because non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Venofer Vial (Iron Sucrose) 100-milligrams/5-milliliters prescribed for iron deficiency. The Part D plan denied the appeal because the drug is excluded from coverage 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 Venofer for your iron deficiency. Venofer is excluded from coverage under the Medicare Part D benefit because there are no conditions under which this drug will be covered. 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. A physician reviewed this appeal and determined that your plan is not required to cover Venofer because there are no conditions under which this drug will be covered under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% ointment prescribed for chronic back and shoulder pain. 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 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 you were prescribed the Lidocaine 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 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

At issue is a tiering exception request for Linzess 145 microgram tablet to irritable bowel syndrome with constipation.  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.Linzess is a brand drug on Tier 2 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. There is no brand drug on a lower eligible tier of the same type that is used to treat your condition. Therefore, your plan is not required to offer you a lower cost share.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol five milligrams prescribed one tablet twice a day for anorexia. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level.Your medical records show your doctor prescribed Dronabinol to treat your condition. However, the Medicare approved compendia does not support the use of this drug for your condition. 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Welchol 625 milligrams to treat unspecified hyperlipidemia.  The Part D plan denied your request because medical necessity was not established. 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 Otezla 30 milligram tablets to treat psoriasis vulgaris. 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. We also researched Medicare systems and reviewed the enrollment data available. The prescriber has not indicated why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. An exception to the plans coverage criteria is not supported. Therefore, the plan is not required to grant an off-formulary exception for Otezla 30 milligram tablets. A physician reviewed your appeal and determined that the plan is not required to cover Otezla 30 milligram tablets because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is the Spiriva handi-haler capsule 18 micrograms prescribed as directed for asthma, other. The Part D plan denied the request stating that the drug requested was not 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 prescriber was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the plans formulary alternatives. We received the documentation and included it in our review.Your medical records show your doctor prescribed Spiriva handi-haler to treat your asthma. Your physician sent answers to the formulary exception questions. However, your medical records do not show all alternative drugs on the plans formulary have been tried or why you cannot take them. Therefore, the drug is not eligible for an off-formulary exception. A physician reviewed your appeal and determined that the plan is not required to cover the Spiriva hand because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Epolamine 1.3 percent patch prescribed for chronic pain. 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. 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 Diclofenac Epolamine 1.3 percent patch because it was not prescribed for a medically accepted indication.