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

At issue is Xifaxan 550 milligram tablets prescribed for an unspecified bacterial intestinal infection. The Part D plan denied coverage because the prior authorization criteria were not met. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation shows Xifaxan was prescribed for unspecified bacterial intestinal infection. The Medicare approved compendia does not support the use of Xifaxan for this condition.A physician reviewed your appeal and determined that the plan is not required to cover Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyndamax 61 milligram capsules to treat transthyretin amyloid cardiomyopathy. The Part D Plan denied the request because prior authorization requirements were not met. 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 the enrollee does not satisfy the Plan's coverage criteria. The prescriber has not sufficiently addressed the Plans coverage criteria. The provided medical records. A physician reviewed your appeal and determined that Vyndamax is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Flector 1.3 percent patch prescribed for radiculopathy of the lumbar region, radiculopathy of the cervical region, and bilateral osteoarthritis of the knees. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Flector 1.3 percent patch to treat your radiculopathy of the lumbar region, radiculopathy of the cervical region, and bilateral osteoarthritis of the knees. 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 Flector 1.3 percent patch because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Uribel to treat urinary urgency and frequency.   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.  Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Bystolic 5 milligram 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 3 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 Humira Pen 40 milligrams/4 milliliters prescribed for the treatment of autoimmune hearing loss. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The 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.A physician reviewed your appeal and determined  that the plan is not required to cover Humira Pen 40 milligrams/4 milliliters because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate 20 milligram tablets for mood disorder. 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 Methylphenidate to treat the enrollees depression, mood disorder, and bipolar disorder. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed your appeal and determined that the plan is not required to cover Methylphenidate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Kineret pre-filled syringe 100 milligram/0.67 milliliter to treat recurrent pericarditis. 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 Trulicity 0.75 milligrams 0.5 pen injector prescribed twice daily for type II diabetes. The Part D plan denied your request for a tiering 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. Trulicity is a brand drug on Tier 3 of the plans formulary. There are no biological 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 tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate HCL ER 36 milligram tablet prescribed for attention deficit hyperactivity disorder. The Part D plan denied your request. 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 has not indicated why all alternatives required by the plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the plans coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met.This decision does not address the medical necessity of the requested drug. It only means that it cannot grant a formulary exception for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec ODT 75 milligram to treat acute migraine headache.  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 prescriber states the enrollee has tried and failed or had an adverse effects with Imitrex, Maxalt, and Zomig.  The prescriber has not indicated why all alternatives required by the plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. 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 Dronabinol 5 milligram capsules to treat weight loss and loss of appetite in an enrollee with chronic pain syndrome. The Part D plan denied your request because the plan indicated you did not have a medically accepted indication for this 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 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.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

At issue is Mupirocin 2% ointment prescribed for the diagnosis of chronic sinusitis. The Part D plan denied your request for a cost-sharing tier exception. We received a request to reconsider the appeal.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 record shows Mupirocin 2% ointment was being prescribed for the treatment of chronic sinusitis. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.In addition, Mupirocin 2% ointment is a generic name on Tier 2 of the plans formulary. There are no generic drugs available in the lower cost-sharing tier to treat the enrollees condition. We have determined that the plan is not required to provide a cost-sharing tier exception.A physician reviewed your appeal and determined that the plan is not required to cover Mupirocin 2% ointment under your Medicare Part D benefit because the enrollees condition is not a medically accepted indication per Medicare approved compendia. Additionally, the cost-sharing tier exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Travasol 10%, Dextrose 70%, and Smofilipid 20% for total parenteral nutrition prescribed for the inability to absorb nutrients due to short bowel syndrome secondary to Crohns 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 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.The records show the enrollee requires total parental nutrition due to malabsorption of nutrients from the intestines. However, if an enrollee cannot absorb nutrition through the intestines due to permanent dysfunction of the gastrointestinal tract, the parental nutrition is subject to Part B and is not eligible to be covered under the Medicare Part D prescription drug benefit. We have determined that the plan is not required to cover the total parental nutrition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 100 milligrams twice a day. The Part D plan denied your request because there was no diagnosis submitted and no response to inquires to determine if the drug was medically indicated. 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. We also researched Medicare regulations and Medicare approved compendia. The prescriber submitted a statement that indicates on further review that you have cancer related neuropathic pain. We asked the prescriber to submit medical records to support your medical condition and history. There was no response from the prescriber. Therefore, the information is insufficient and 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 drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligrams prescribed for circadian rhythm sleep disorder, free running type. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. The prior authorization information requested was not received by the plan. We received a standard 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 drug is medically indicated for your diagnosis. However, the plan requires certain prior authorization guidelines be met before approving this drug. For initial therapy for non-24-hour sleep-wake disorder, the plan requires a diagnosis of total blindness in both eyes and the inability to perceive light in both eyes. If currently on the medication, the plan requires you to meet one of the following: a) increased total nighttime sleep or b) decreased daytime nap duration. The documentation received does not show that you have satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate 10 milligrams three times daily prescribed for chronic pain. 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 Methylphenidate to treat your chronic pain from rheumatoid arthritis. The prescriber sent a letter dated 2/1/2021 stating that the requested drug is an adjunct treatment for chronic pain.  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 Methylphenidate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methocarbamol, 500 milligram tablets prescribed on October 30, 3020. Your Part D plan did not make a timely decision and submitted the appeal to Maximus for review on November 2, 2020. We received an auto forwarded 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.We asked your doctor to send us information regarding your condition. We also asked for a prior authorization, medical records, and other documentation to show why you need this medication. We did not receive the documentation requested. The record shows your doctor prescribed Methocarbamol to treat an unknown condition. The plan requires a prior authorization be initiated by your physician before they will consider covering the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Methocarbamol because no prior authorization or medical records were submitted.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bystolic 5 milligrams prescribed twice daily for essential hypertension. The Part D plan denied your request for a tiering exception because there is no alternative brand name drugs for the enrollees condition in 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. Bystolic 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 cover Bystolic at a lower cost.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Austedo 6 milligrams two daily prescribed for bipolar disorder. 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 Austedo to treat your bipolar disorder. However, the Medicare approved compendia does not support the use of this drug for your condition. The submitted documentation states an incorrect diagnosis was on the original prior authorization. The correct diagnosis is tardive dyskinesia. However, there were no medical records submitted to confirm this diagnosis.A physician reviewed your appeal and determined that the plan is not required to cover Austedo.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Arikayce prescribed daily for mycobacterium asbcessus. The Part D plan denied your request because the drug has not approved 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 Arikayce to treat your mycobacterium asbcessus. 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 drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is the Estradiol 0.0375 milligram patch prescribed as directed for menopausal and female climacteric state. 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. 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 Estradiol 0.0375 milligram patch 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 Estradiol patch because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydrocodone-Chlorpheniramine ER prescribed every 12 hours as needed to treat the enrollees condition. The Part D plan denied your request because the medication is used to treat cough and/or cold symptoms, which is an excluded drug category. 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. We determined that the plan is not required to reimburse Hydrocodone-Chlorpheniramine ER because it it was for the symptomatic relief of coughs and colds. Drugs prescribed for symptomatic relief of cough and colds are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Invokana 300 milligram tablets once per day for type 2 diabetes mellitus. The Part D plan denied your request for a tiering exception because there is no alternative brand name drug, for the same condition, in 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. We also researched Medicare systems and reviewed the enrollment data available. The drug is medically accepted for treatment of diabetes. The prescriber indicated that the enrollee had tried Farxiga and Metformin for this condition but had an intolerance to both. However, Invokana is a Brand drug on Tier 3 of the plans formulary. The plans formulary does not include any other Brand medications on a lower Tier to treat the same condition. 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.