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

You requested Ipratropium/Albuterol Sulfate Solution 0.5/2.5 (3)/milligrams/3 milliliters prescribed for pulmonary hypertension, shortness of breath, and wheezing. The Part D plan denied the request because the diagnoses do not meet the requirements of medically accepted indications. 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 Ipratropium/Albuterol Sulfate Solution is prescribed for pulmonary hypertension, shortness of breath, and wheezing. However, the Medicare approved compendia do not support the use of this drug for your conditions. A physician reviewed your appeal and determined that the plan is not required to cover Ipratropium/Albuterol Sulfate Solution because your diagnoses do not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement of the cost of 2 tablets of Celecoxib. The Part D plan did not provide a timely redetermination decision. We received an 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 regulations and Medicare approved compendia. The plans formulary includes the drug Celecoxib and a quantity limit is noted to be 60 tablets per 30 days. However, the information submitted is insufficient to determine if the medication was medically indicated. The diagnosis or condition requiring the drug is not submitted. Therefore, it is unable to be determined if the drug is eligible for reimbursement.   Our Physician Reviewers opinion is that the plan is not required to reimburse the cost of Celecoxib.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sirolimus 1 milligram tablets prescribed as 2 tablets daily following a heart transplant. You requested that the plan provide coverage for a drug that has prior authorization criteria. The plan did not make a decision within the required timeframe. 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We asked your prescriber to send us information regarding your condition. We did not receive the documentation requested.The prescriber statement shows Sirolimus was prescribed following a heart transplant. Medicare enrollment records show you were entitled to Medicare Part A coverage on February 1, 2012. The documentation available for review does not include the date of your organ transplant. There is insufficient documentation to show you have satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Sirolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hizentra 10 gram/50 milliliter vial prescribed as directed for mononeuritis multiplex vasculitis. The Part D plan denied the request for 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 was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the plans formulary alternatives. We received the documentation and included it in our review.Your medical records show your doctor prescribed Hizentra to treat your condition. The medical records do not support a medically accepted indication for your condition. Systemic vasculitis is not supported. 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 your appeal and determined that the plan is not required to cover the Hizentra because all alternative drugs on the plans formulary have not been tried.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Mycophenolate Mofetil 500 milligram tablets to treat the prevention of lung transplant rejection.   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.Based on the information provided, we determined the drug could be eligible for coverage under Part D.  There is no information in the Medicare Database that indicates you had a covered transplant, paid for by Medicare.The American Hospital Formulary Service Drug Information (AFHS-DI) has a positive citation:  Mycophenolate Mofetil and Mycophenolate Sodium have been used for the prevention of rejection of lung allografts in patients who have undergone lung transplantation. Following lung transplantation, acute allograft rejection and chronic lung allograft dysfunction, including bronchiolitis obliterans syndrome (BOS), are major complications affecting long-term graft and patient survival. Several clinical trials and clinical experience to date indicate that Mycophenolate used in combination with other immunosuppressants is effective in the prevention of allograft rejection following lung transplantation.The documentation satisfies the plans coverage criteria.  A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate Extended Release 27 milligram tablets to treat attention deficit hyperactivity disorder. The Part D plan denied your request. 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 also researched Medicare regulations and Medicare approved compendia. The enrollee is prescribed another medication that could cause a possible drug interaction and there is no indication that the enrollee will be taken off that medication or indication that not taking both drugs would be of more harm than good. Therefore, the requested drug is not eligible for coverage under Medicare Part D.Our Physician Reviewers opinion is that the plan is not required to cover Methylphenidate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Docusate Sodium 100 milligram Softgels to treat constipation. The Part D plan denied the request. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read 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.This drug is available over the counter and is non-prescription. Non-prescription drugs are excluded from Medicare Part D drug benefits.Our Physician Reviewers opinion is that the plan is not required to cover Docusate Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lastacaft 0.25% eyedrops prescribed as directed for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug you requested is not included on the plans formulary.  We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber was asked questions to clarify the medical history and to provide documentation to support a diagnosis. The prescriber was also asked questions to address all lower tier drugs of the same type on the plans formulary.The record shows you were prescribed Lastacaft eye drops. Since the drug isnt on the plans formulary it is not eligible for a tiering exception. 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 the Lastacaft.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz 5 milligram tablets prescribed twice daily for vitiligo.  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 Lunesta 2 milligrams prescribed as directed for insomnia. 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 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 you were prescribed Lunesta for your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided does not show the coverage criteria has been met. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the Lunesta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ergocalciferol 50,000 units prescribed for unknown diagnosis. The plan denied the request because the drug is excluded from coverage under Part D benefit. 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.According to Medicare rules, drugs that fall into the category of vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover Ergocalciferol. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xarelto 20 milligrams prescribed for an unknown diagnosis. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level. 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. The prescriber was also asked questions to address the Plans tiering exception criteria. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Olmesartan-Amlodipine-HCTZ tablets to treat hypertension. The Part D plan denied your request for a tiering exception for this covered drug at a lower cost tier. 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 documentation shows Olmesartan-Amlodipine-HCTZ was prescribed; however, Olmesartan-Amlodipine-HCTZ is not on the plans formulary. Therefore, cannot be 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

You requested Motegrity two-milligram tablets prescribed for irritable bowel syndrome. 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. The Medicare approved compendia does not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees diagnosis.  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 Motegrity. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine HCL 2% jelly prefilled applicator prescribed three times daily for hemorrhoid pain. The Part D plan denied your request because the quantity limit requested is higher than what the plan allows. 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 Lidocaine HCL 2% jelly prefilled applicator to treat your condition. The amount you were prescribed exceeds the plans number of doses that may be dispensed. There was no supporting evidence submitted to show why you require this amount. Therefore, an exception to the amount of drug requested cannot be made as the limit criteria was not met. A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine HCL 2% jelly prefilled applicator, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Horizant 300 milligram tablet prescribed as directed to treat idiopathic progressive neuropathy. 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 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 medical records show your doctor prescribed Horizant to treat your condition. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, a formulary exception cannot be considered. A physician reviewed your appeal and determined that the plan is not required to cover the Horizant.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dextraoamphetamine/Amphetamine ER 30 milligram capsules to treat mild cognitive impairment, unspecified depression, and energy. The Part D plan denied your request because the provided diagnoses do 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 Dextraoamphetamine/Amphetamine ER 30 milligram capsules daily to treat your mild cognitive impairment, unspecified depression, and energy. 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 Dextraoamphetamine/Amphetamine ER because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Octreotide Acetate Sodium 100 microgram/milliliter Solution to treat other specified functional intestinal disorders, chronic intestinal pseudo obstruction. The Part D plan denied your request. 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 also researched Medicare regulations and Medicare approved compendia. 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. The drug is not approved by the food and drug administration to treat the diagnoses submitted. Therefore, the requested drug is not eligible for coverage under Medicare Part D.Our Physician Reviewers opinion is that the plan is not required to cover Octreotide Acetate Sodium Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydroxychloroquine 200 milligram tablet prescribed as directed for osteoarthritis. The Part D plan denied your 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. Your medical records show your doctor prescribed Hydroxychloroquine to treat your condition. 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 Hydroxychloroquine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Multaq 400 milligram oral tablets prescribed daily for atrial fibrillation. 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. Multaq is a brand drug on Tier 3 of the plans formulary. The prescriber statement shows Multaq was prescribed to treat atrial fibrillation, and that alternative antiarrhythmic drugs were tried and failed. However, 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

Nuedexta 20-10 milligram capsule is prescribed twice daily for pseudobulbar affect. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level.Your medical records show your doctor prescribed Nuedexta to treat pseudobulbar affect. The Medicare approved compendia do support the use of this drug for your condition.However, the plan requires a diagnosis of pseudobulbar affect due to either amyotrophic lateral sclerosis or multiple sclerosis before they will cover 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 Nuedexta. The prior authorization criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Adderall Extended Release tablets to treat severe fatigue due to primary progressive multiple sclerosis. The Part D plan denied your request. 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 also researched Medicare regulations and Medicare approved compendia. 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. The drug is not approved by the Food and Drug Administration to treat the diagnoses submitted. Therefore, the requested drug is not eligible for coverage under Medicare Part D.Our physician reviewers opinion is that the plan is not required to cover Adderall.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxyzine Hydrochloride 25 milligram tablets to treat a chronic cough. The Part D plan denied your request. 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 also researched Medicare regulations and Medicare approved compendia. 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. The drug is not approved by the Food and Drug Administration to treat the diagnosis submitted. Therefore, the requested drug is not eligible for coverage under Medicare Part D.Our Physician Reviewers opinion is that the plan is not required to cover Hydroxyzine Hydrochloride.