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

You requested Diclofenac Epolamine 1.3 percent patch prescribed for chronic pain syndrome. 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 Diclofenac Epolamine 1.3 percent patch to treat your chronic pain syndrome. 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 Diclofenac Epolamine 1.3 percent patch because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ondansetron 4 milligrams prescribed for nausea and vomiting status-post stroke. The Part D plan denied your request because the medication is 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. The records show you prescribed Ondansetron to treat the enrollees nausea and vomiting status-post stroke. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Ondansetron.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lantus Solostar 100 units/milliliter pen prescribed 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 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.Lantus Solostar 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

You requested Terbutaline Sulfate 5 milligram tablets prescribed for bradycardia following a heart transplant. 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 the drug for bradycardia following a heart transplant. 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 Lantus Solostar 100 units per 1 milliliter, 20 units subcutaneous prescribed daily at bedtime for type 2 diabetes. The Part D Plan denied the request for a tiering exception because there are no lower cost insulins on the plans 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.Lantus Solostar 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

You requested Dronabinol 2.5 milligrams twice daily prescribed for weight loss secondary to dementia. The Part D plan denied your request because Medicare approved compendia have not approved the use of this drug for the diagnosis provided. 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 Dronabinol. The medical records show that Dronabinol was prescribed to treat the enrollees weight loss. The Medicare approved compendia does support the use of this drug for weight loss when associated with chemotherapy treatments or Acquired Immune Deficiency 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

At issue is Oxycontin CR 30 milligram tablets prescribed for severe pain. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Your physician submitted a supporting statement. The documentation indicates the physician had prescribed Oxycontin CR to treat your severe pain. The Medicare approved compendia support the use of the requested drug for your condition.However, the records do not show why you cannot take other drugs on your plans formulary for your condition. Your physician did not indicate all alternatives to treat your condition on the plans formulary have been tried and failed.A physician reviewed your appeal and determined that the plan is not required to cover the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vimpat 100 milligram tablets prescribed as directed for epilepsy with partial seizures. 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 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. Vimpat 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: Unfavorable

You requested Gleostine 100 milligram capsule prescribed for the treatment of astrocytoma. The Part D plan denied your request because the drug was excluded from coverage under Medicare Part D because it is a brand drug, and its manufacturer has not signed the Medicare Coverage Gap Discount Agreement. 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 Gleostine is excluded from coverage under Medicare Part D because it is a brand drug and its manufacturer has not signed the Medicare Coverage Gap Discount Agreement. According to Medicare rules, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. According to the list, the manufacturer, NextSource biotechnology, did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, we determined that the plan is not required to cover the Gleostine. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Procrit 20,000 units prescribed every two weeks for anemia in end stage renal disease. 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 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 the enrollee was ordered Procrit, has end stage renal disease, and is on dialysis. However, this drug is eligible for coverage under Medicare Part B.We determined that the plan is not required to cover Procrit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexletol, 180 milligram tablets prescribed daily for pure hypercholesterolemia. 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 an expidited 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 show that your doctor prescribed Nexletol to treat your hypercholesterolemia. The Medicare approved compendia do support the use of this drug for your condition. The documentation does not satisfy the plans coverage requirements. 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 requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dipyridamole 75 milligrams tablets prescribed twice daily for thromboembolic disorder prophylaxis in an enrollee with a coronary artery bypass graft. 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. We also researched Medicare systems and reviewed the enrollment data available.The records show you prescribed Dipyridamole as a prophylaxis for thromboembolic disorder status-post coronary artery bypass graft. The plan requires Dipyridamole be used as an adjunct to Warfarin therapy in the prevention of postoperative thromboembolic complications of cardiac valve replacement, before they will cover the requested drug. You have indicated that Dipyridamole is not being used as an adjunct to Warfarin therapy in the prevention of postoperative thromboembolic complications of cardiac valve replacement. 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 Dipyridamole.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lyrica 150 milligrams prescribed twice daily for chronic pancreatitis. 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 Lyrica 150 milligrams twice daily 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 Lyrica 150 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Northera 100 milligrams three times daily prescribed for symptomatic neurogenic orthostatic hypotension. The Part D plan denied your request because Medicare approved compendia have not approved the use of this drug for the diagnosis provided. In addition, a tiering exception cannot be granted on a drug in Tier 5 (Specialty 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. The prescribing physician (also requesting physician) submitted a letter of medical necessity but no medical records as requested by the plan. A physician reviewed your appeal and determined that the plan is not required to cover the Northera. The Medicare approved compendia do support the use of this drug for symptomatic neurogenic orthostatic hypotension. However, the documentation provided does not show the enrollee has satisfied the plan's coverage criteria for prior authorization. As the drug cannot be covered, tiering exception is not addressed.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ofev 100 milligram capsules prescribed for interstitial lung disease. 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 the drug for interstitial lung disease. The medical records indicate the enrollee has connective-tissue-disease-related interstitial lung disease. 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 Leflunomide 20 milligram tablets prescribed for rheumatoid arthritis. The Part D Plan denied your request for a tiering exception because the prescriber statement didn't explain why the alternative drugs in a lower tier wouldn't work just as well. 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. Leflunomide  is a generic drug on Tier 3 of the plans formulary. You did not address why the alternative drugs on lower cost-sharing tiers of the plans formulary would not work for the enrollee. All generic drugs on lower tiers have not been tried. 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 Lidocaine 5% patch to treat lower extremity pain due to varicose veins.  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 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ondansetron four milligrams prescribed for nausea and vomiting secondary to abdominal pain and constipation. 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 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 Ondansetron to treat your nausea and vomiting. However, the Medicare approved compendia 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 Ondansetron.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nystop powder, 100,000 units per gram prescribed for candidiasis of the skin. 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 submitted medical records show that Nystop was prescribed to treat candidiasis of the skin. The Medicare approved compendia support the use of the requested drug for this condition. However, the submitted documentation does not address why the alternative drugs listed in the plans formulary have not been tried to treat your condition, or are contraindicated. Therefore, the plan will not cover the drug as an off-formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover the drug as an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Chlordiazepoxide-Clidinium 5/2.5 milligrams prescribed daily for irritable bowel syndrome with diarrhea. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The plan requires your physician to indicate why the formulary drugs would not be as effective as the requested drug and/or that the enrollee would have adverse effects before they will cover the requested Chlordiazepoxide-Clidinium. A physicians statement was submitted and stated you had been treated with this drug since 2013. Medicare approved compendia supports the use of the requested drug for your condition. However, the physician did not state 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 Chlordiazepoxide-Clidinium. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armour Thyroid 90milligrams to treat hypothyroidism.  The Part D plan denied the request.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read 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.Non-FDA approved drugs are excluded from Medicare Part D coverage.  Per the Medicare approved compendia, This drug has not been found by the US FDA to be safe and effective, and the drug product labeling has not been approved by the FDA. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Chlordiazepoxide-Clidinium, 5 milligram-2.5 milligram capsules prescribed for irritable bowel syndrome without diarrhea. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Chlordiazepoxide-Clidinium as an off-formulary exception.The submitted medical records show that Chlordiazepoxide-Clidinium was prescribed to treat the enrollees irritable bowel syndrome. The Medicare approved compendia support the use of the requested drug for this condition. However, the submitted documentation does not sufficiently address why all of the alternative drugs listed in the plans formulary to treat irritable bowel syndrome have not been tried, or are contraindicated. Therefore, the plan will not cover the Chlordiazepoxide-Clidinium as an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac 1% gel prescribed for connective tissue disease. The Part D plan denied your request because the medication is 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. The records show you prescribed Diclofenac gel to treat the enrollees connective tissue disease. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac gel.