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

You requested Dextroamphetamine/Amphetamine 30 milligrams prescribed twice daily for hypersomnia. The Part D plan denied your request because the 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. Your medical records show your doctor prescribed the requested drug to treat your hypersomnia. However, 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Genvoya to treat the enrollee's condition. 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.Genvoya is a brand drug on Tier 5, a specialty tier, of the plans formulary. Drugs on the plan's specialty tiers are 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 Xarelto 20 milligram tablets prescribed daily for chronic atrial fibrillation. The Part D plan denied your request for a tiering 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.We asked your prescriber to send us information about your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why similar medications on the lower teirs would not work for you.  We did not receive the documentation requested.Xarelto is a brand drug on Tier 3 of the plans formulary. The prescriber statement shows Xarelto was prescribed to treat chronic atrial fibrillation and to prevent future blood clots or a cerebral vascular accident. However, the plans formulary includes Jantoven, which is a brand drug in the same class as Xarelto on Tier 1. The prescriber did not address why Jantoven would not work for the enrollee. All brand drugs of the same type on the lower cost sharing 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 a tiering exception request for Xanax 0.25 milligrams to treat the enrollee's condition. 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. Xanax is a non-formulary drug and 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 Armodafinil to treat fatigue related to multiple sclerosis. 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 the enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humalog mix 75/25 KwikPen 100 units per milliliter prescribed daily for type 2 diabetes mellitus. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited auto-forwarded reconsideration request from the plan. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your physician submitted a supporting statement and medical records. The medical records show the physician had prescribed Humalog mix 75/25 KwikPen to treat your type 2 diabetes mellitus. The Medicare approved compendium supports 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. Specifically, your physician submitted a prescriber statement that indicates you have not tried all of the alternative drugs to treat your type 2 diabetes mellitus. Your medical records do not show all alternative drugs on the plan formulary have been tried or why you cannot take them.A physician reviewed your appeal and determined that the plan is not required to cover Humalog mix 75/25 KwikPen because the documentation did not support an off-formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is METHYLPHENIDATE HCl 10 mg tablet to treat fatigue related to multiple sclerosis.  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 the enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armodafinil 250 milligram tablets prescribed as directed for fatigue related to multiple sclerosis. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows the doctor prescribed Armodafinil to treat fatigue related to multiple sclerosis. However, the Medicare approved compendia do not support the use of Armodafinil for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Emgality 120 milligram/milliliter auto-injector prescribed once monthly for new daily persistent headaches. The Part D plan denied your request because the medication is 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 medical records show you prescribed Emgality for new daily persistent headaches. It is noted that your statement indicates that Emgality is being prescribed for migraines; however, the diagnosis noted in your statement is not supported in the medical records provided. The Medicare approved compendia do not support the use of this drug for the condition noted in the medical records provided. A physician reviewed your appeal and determined that the plan is not required to cover Emgality.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Guanfacine 2 milligram ER tablet prescribed daily for chronic motor tic disorder. The Part D plan denied your request because the medication 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 records show you prescribed Guanfacine 2 milligram ER tablet to treat the enrollees chronic motor tic disorder. 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 Guanfacine 2 milligram ER tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Azathioprine 50 milligrams prescribed for idiopathic thrombocytopenic purpura. 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 Azathioprine for idiopathic thrombocytopenic purpura. In review of the Medicare approved compendia, idiopathic thrombocytopenic purpura is not a medically accepted indication for Azathioprine. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Azathioprine at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Imatinib Mesylate 400 milligrams prescribed for a nonresectable malignant neoplasm of the brain, unspecified and teratoma. 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 Imatinib Mesylate for a nonresectable malignant neoplasm of the brain, unspecified and teratoma. In review of the Medicare approved compendia, nonresectable malignant neoplasm of the brain, unspecified and teratoma is not a medically accepted indication for Imatinib Mesylate. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Imatinib Mesylate at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Silodosin 4 milligram capsules prescribed daily for benign prostatic hyperplasia. 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 physician submitted a supporting statement and medical records. The medical records show the physician had prescribed Silodosin to treat benign prostatic hyperplasia. The Medicare approved compendia do support the use of Silodosin for this condition.The physician states the enrollee could not tolerate Tamsulosin due to dizziness. However, the records do not show why the enrollee cannot take other drugs on the plans formulary for benign prostatic hyperplasia. Specifically, the documentation does not show that the enrollee tried and failed, or was unable to safely try, all alternative drugs.A physician reviewed your appeal and determined that the plan is not required to cover Silodosin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Deferasirox 360 milligram tablets prescribed for chronic iron overload in an enrollee with transfusion-dependent anemia. The Part D plan denied coverage because prior authorization criteria was not met. 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. The enrollee does not satisfy the plan's coverage criteria. The prescriber states the enrollees platelet count is 6 x 10(9)/L.  Deferasirox is contraindicated for patients with platelet counts less than 50 x 10(9)/L.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 Modafinil, 100 milligram tablets for the treatment of other hypersomnia. The Part D plan denied your request because other hypersomnia is not a Food and Drug Administration-approved diagnosis for the use of this medication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.  A physician reviewed your appeal and determined that the plan is not required to cover the Modafinil because other hypersomnia is not a medically accepted indication to use this drug.The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law.  As such, the requested drug does not meet the definition of a Medicare Part D drug and is therefore not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Xifaxan 550 milligrams prescribed for dysphagia, unspecified, and other fecal abnormalities. 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 Xifaxan for dysphagia, unspecified, and other fecal abnormalities. In review of the Medicare approved compendia, dysphagia, unspecified, and other fecal abnormalities is not a medically accepted indication for Xifaxan. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Xifaxan at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xerava 50 milligrams injection prescribed for pneumonia (gram negative multi-drug resistant organism).  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 the enrollees condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dexilant DR, 60 milligram capsules, prescribed for gastroesophageal reflux disease. The Part D Plan denied your request for a tiering exception because there were no lower tier alternatives of the same type on the plans formulary. 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. A physician reviewed your appeal and determined that the plan is not required to cover the Dexilant DR at a lower cost tier.Dexilant DR is a brand name drug on Tier 4 of the plans formulary. There are no brand name drugs on the lower cost sharing tiers. There must be a drug of the same type, brand name drug, on a lower tier of the plans formulary for a tiering exception to be granted. Therefore, this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Adcirca, 20 milligram tablets, prescribed once daily for pulmonary artery hypertension. The Part D plan denied your request because the documentation did not support an off-formulary exception. 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 information submitted at the reconsideration level. A physician reviewed your appeal and determined that the plan is not required to cover the Adcirca as an off-formulary exception.Your doctor submitted a supporting statement stating that Adcirca was prescribed to treat your pulmonary artery hypertension. The Medicare approved compendia support the use of the requested drug for your condition.However, the documentation does not support that the formulary alternatives to treat your condition have been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clobazam 10 milligrams prescribed for epilepsy and epileptic syndromes with simple partial seizures. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an auto-forwarded reconsideration request from the coverage level. Of note, you requested a quantity in excess of quantity limit criteria.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 the requested drug to treat your epilepsy and epileptic syndromes with simple partial seizures. However, 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Bystolic 5 milligram tablet to treat hypertension. 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.Bystolic is a Brand drug on Tier 4 of the plans formulary. There are no Brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. 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 Januvia 100 milligram tablets prescribed daily for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other brand drugs on a lower cost-sharing tier. We received 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.Januvia is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ninlaro, 4 milligram capsules prescribed for cancer. The Part D Plan denied your request for a lower-cost tiering exception because the medication is included in the plans 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. A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.Ninlaro is listed on your plans formulary as Tier 5, which is the tier for specialty drugs. The plan does not grant tiering exceptions for specialty drugs. Therefore, this drug is not eligible for coverage at a lower-cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rosuvastatin 10 milligram tablets prescribed as directed for dyslipidemia. The Part D plan denied your request for a tiering exception the documentation did not show that all generic drugs on lower tiers had been tried or considered for the treatment of dyslipidemia. 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. Rosuvastatin calcium is a generic drug on Tier 2 of the plans formulary. The doctor submitted a supporting statement without medical records. The plans formulary includes other medications of the same class on Tier 1. The doctor did not address why alternative generic drugs on lower tiers would not work. Therefore, Rosuvastatin 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.