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

At issue is Epclusa 400/100 micrograms tablets prescribed for chronic viral hepatitis C. The Part D plan denied coverage because prior authorization is required 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 records submitted at the reconsideration level. The documentation supports Epclusa was prescribed for chronic viral hepatitis C. However, the enrollee does not satisfy the plan's coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria, as there was no evidence of failed prior treatment with drug combinations Peginterferon alfa and Ribavirin, or Sovaldi and Ribavirin.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Benztropine Mesylate 0.5 milligram tablets prescribed for disturbances of salivary secretion. 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 Benztropine Mesylate for excessive salivation from medication. This is an off-label use of the drug. The Medicare approved compendia do not contain citations to 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 Corlanor 5 milligram tablets prescribed for sinus tachycardia. 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 Corlanor for sinus tachycardia. 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 Lumigan 0.01% solution prescribed daily for primary open-angle glaucoma, bilateral, severe stage. The Part D Plan denied your request for a tiering exception because there are no lower tier alternatives for your condition. 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. Lumigan 0.01% solution is a brand drug on Tier 3 of the plans formulary. The prescriber statement shows the solution is used to treat your condition. 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 Benlysta 200 milligram\milliliter auto-injector pen prescribed daily for systemic lupus erythematosus. 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 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 records submitted at the reconsideration level. Your medical records show your doctor prescribed Benlysta to treat 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 enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover the Benlysta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gocovri ER 137 milligrams capsules. The Part D plan denied your request for a non-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 records submitted at the reconsideration level. The physician submitted a supporting statement. The prescriber statement indicates that Gocovri ER is prescribed to treat dyskinesia in Parkinsons disease, and that the enrollee has tried other alternatives. However, medical records have not been submitted for review. Therefore, the documentation available does not show the enrollee has satisfied the plan's coverage criteria.Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Belbuca 450 microgram film to treat low back and leg pain. 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.Belbuca is a brand drug on Tier 4 of the plans formulary. 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, a tiering exception cannot be covered by the plan.A physician reviewed your appeal and determined that the tiering exception criteria have not been met and the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Belbuca 450 microgram film prescribed as directed for chronic pain. The Part D plan denied your request for a tiering exception because there were no brand drugs of the same type on the lower cost sharing tiers. 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.Belbuca 450 microgram film 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.Our Physician Reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Colistimethate Sodium 150 milligrams to treat bronchiectasis exacerbation with pseudomonas infection and mycobacterium avium complex. 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.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. A physician reviewed your appeal and determined that the plan is not required to cover Colistimethate Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Lidocaine 5% ointment, 50 grams per 30 days. The Part D plan denied the request because the amount of Lidocaine prescribed was more than what was allowed by the plan for a 30-day supply. Additionally, the Lidocaine ointment was prescribed for 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. Your doctor has indicated the Lidocaine ointment is being prescribed for your osteoarthritis of the knees. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted conditions. Therefore, the requested drug is not eligible for coverage under Medicare Part D. Since the drug in not eligible for coverage under Medicare Part D, the amount of medication prescribed by your doctor will not be addressed.A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vitamin A-Vitamin E-Hyaluronic Acid Gel compounded product.   The Part D plan denied the request.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed for use as vitamins and minerals are excluded from coverage under Medicare Part D. Bulk powders used in pharmacy compounding are not reviewed and approved for safety and efficacy by the FDA and therefore do not meet the definition of a covered [Part D] drug. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prozac 20 milligram oral capsule prescribed for to treat anxiety disorder. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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. 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.A physician reviewed your appeal and determined that the plan is not required to cover Prozac.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sodium Phenylbutyrate 500 milligram tablet prescribed for Amyotrophic Lateral Sclerosis. 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 Sodium Phenylbutyrate to treat your Amyotrophic Lateral Sclerosis. 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 Sodium Phenylbutyrate because your diagnosis does not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine Hydrochloride 10 milligram oral tablet prescribed daily for intervertebral disc degeneration. The Part D plan denied your request because the requested drug was not prescribed for 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.Initially the medical records show Cyclobenzaprine Hydrochloride was prescribed to treat intervertebral disc degeneration. The prescriber statement submitted states the enrollee was treated for a diagnosis of muscle spasms. However, the medical records submitted at redetermination and at reconsideration show the requested drug was prescribed for intervertebral disc degeneration. The medical records do not support a diagnosis muscle spasms. 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 Cyclobenzaprine Hydrochloride. The requested drug is not eligible for coverage under Medicare Part D for the noted condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo 4 milligram tablet. The Part D plan denied your request for a tiering. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Livalo is a brand drug that is not on the plans formulary. Your plan has already granted a formulary exception for the drug. A tiering exception cannot be allowed for a drug that is not on the plans formulary. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate hydrochloride extended release 10 milligrams daily to treat chronic fatigue, unspecified. 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 a tiering exception request for Leflunomide 20 milligram tablet to treat rheumatoid arthritis.   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.Leflunomide is a generic drug on Tier 3 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. Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Freestyle Libre 14 day Sensor prescribed for monitoring blood sugar. The Part D plan denied the request because the device is not directly related to the delivery of insulin to the body. Medicare Part B covers medical supplies that are not directly related to the delivery of insulin to the body. 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 Lidocaine/Prilocaine 2.5% cream is prescribed for your Type 2 diabetes mellitus. The Medicare Part D Prescription Drug benefit does not cover devices that are not directly related to the delivery of insulin to the body. Those items are covered under the Medicare Part B. We determined that the plan is not required to cover Freestyle Libre 14 day Sensor. Medicare Part B is responsible for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62% gel to treat hypogonadism, late-onset.  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. Per the compendia, The safety and efficacy of testosterone therapy have not been established in men with late-onset (age-related) hypogonadism. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Symbicort 80-4.5 micrograms/actuation inhaler prescribed for chronic obstructive pulmonary disease. 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 prescriber has not provided patient specific clinical rationale as to 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 formulary coverage criteria is not supported.  A physician reviewed your appeal and determined that the plan is not required to cover Symbicort.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Monurol 3 milligram packet prescribed for prophylaxis of urinary tract infection. 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 Monurol for prophylaxis of urinary tract infection. 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 Xifaxan 550 milligram tablet to treat the diagnosis of small intestinal bacterial overgrowth. 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. 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 Nuedexta 20 milligram-10 milligram capsules prescribed 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 submitted documentation indicates your doctor prescribed Nuedexta for pseudobulbar affect nor related to amyotrophic lateral sclerosis or multiple sclerosis. 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 Oxazepam 30 milligram capsule prescribed for an unknown diagnosis. The Part D plan denied your request for a formulary exception. 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 prescriber was asked to state the diagnosis since the diagnosis was not contained within the appeal. The prescriber was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis and formulary alternatives tried and failed. A response from the prescriber was not received. Therefore, based upon the current record, 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.