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

You requested Vascepa 1 gram capsules prescribed to treat hypercholesterolemia in an enrollee with coronary artery disease. 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. 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 Vascepa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Reyvow as directed. The Part D plan denied your request for a tiering exception because the drug you requested has been approved as a non-formulary 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 record shows you were prescribed Reyvow. 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 Reyvow because the drug isnt on the plans formulary so it is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pregabalin 200 milligram capsules prescribed three times a day for spinal stenosis. The Part D plan denied your request for a tiering exception 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. The documentation shows the doctor prescribed Pregabalin to treat the enrollees complaints of burning pain in the feet, due to spinal stenosis. However, the Medicare approved compendia do not support the use of Pregabalin for this condition. Since the drug was not prescribed for a medically accepted indication, the drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to cover Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac sodium 3% gel to treat Bowens disease.  The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  We received an auto-forwarded reconsideration request from the plan We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.  The 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 Jardiance 10 milligrams prescribed daily for type 2 diabetes mellitus. The Part D plan denied your request for a tiering exception because there are no lower tier alternatives for the enrollees condition. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Jardiance 10 milligrams 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 Promacta 50 milligram tablets prescribed daily for chronic immune thrombocytopenic purpura. 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. The medical records show you prescribed Promacta to treat the enrollees chronic immune thrombocytopenic purpura. The Medicare approved compendia do support the use of this drug for your condition.The plan requires evidence the enrollee has a platelet count less than 50,000 microliters with an increased risk for bleeding and has tried one other therapy or has undergone a splenectomy 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 Promacta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Symbicort 160-4.5 microgram/ Hydrofluoroalkane aerosol with adapter to treat chronic obstructive pulmonary disease. 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.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 Diclofenac Sodium 3% gel to treat polyneuropathy.  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 Cyanocobalamin 1000 micrograms/milliters to treat Vitamin B12 deficiency. 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.Prescription vitamins and mineral products are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage. We have determined the plan is not required to cover Cyanocobalamin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Stelara 90 milligrams/milliliter, 2 ml for 28 days prescribed for hidradenitis suppurativa. 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.Your medical records show your doctor prescribed Stelara to treat your hidradenitis suppurativa. The Medicare approved compendia do not support the use of this drug for your condition. Therefore, Medicare does not cover this drug for your condition. As such, the prior authorization and quantity limit guidelines were not reviewed. A physician reviewed your appeal and determined that the plan is not required to cover Stelara.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 20 milligram tablets prescribed daily for pulmonary hypertension, unspecified. 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 record shows you were prescribed Sildenafil Citrate for pulmonary hypertension, unspecified. The enrollee does not satisfy the plan's coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not provided documentation of pulmonary hypertension by right heart catheterization. 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 Vascepa 1 gram capsule to treat mixed hyperlipidemia. 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 coverage for Repatha Sureclick 140 milligrams injection prescribed for pure hypercholesterolemia, unspecified. The Part D plan denied your request for a formulary exception. We received an expedited reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Repatha Sureclick to treat your pure hypercholesterolemia, unspecified. The Medicare approved compendia support the use of this drug for your condition. Your doctor submitted a prescriber statement indicating that you tried Atorvastatin. This drug did not improve your condition. However, the plan formulary includes other drugs that could be used to treat your condition. Your records do not show that all alternative drugs on the plan formulary have been tried or why you cannot take them. 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 Oxycodone Hydrochoride 30 milligram tablet, 120 tablets per 30 days, to treat chronic pain.   The Part D plan denied the request.  We received a reconsideration request. We performed an independent and de novo review. To make our decision, we read 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 indicated that the accumulated morphine milligram equivalent warranted to treat the enrollee's pain is 294 milligrams/day.  The accumulated morphine milligram equivalent of one or more of the enrollee's opioid prescriptions is 360 milligrams/day.  Therefore, an exception to the plans coverage criteria is not supported.  Our Physician Reviewer's opinion is that quantity limit criteria are not met
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sirolimus 1 mg tablet to treat Gorham-Stout Disease with complicated lymphatic anomaly. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read 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 Eliquis 5 milligram tablet prescribed twice a day. The Part D plan was unable to make a determination within the timeframe for your request to cover this drug at a lower tier cost. We received an expedited auto-forwarded reconsideration request from the plan.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. Non-formulary drugs cannot be provided at a lower tier cost. Eliquis is a non-formulary approved drug and is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception for the Eliquis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamin 1.3% patch to be applied two times a day for chronic lumbar spondylosis. The Part D plan denied the drug because it was not medically necessary. The plan requires prior approval before covering some 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level.Diclofenac Epolamin 1.3% patch is being requested to treat chronic lumbar spondylosis. The Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover the Diclofenac Epolamin 1.3% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid tablets 100 micrograms prescribed as 45 tablets per a 90 day supply for hypothyroidism. The Part D Plan denied your request for a tiering exception because the plans list of covered drugs did not include any other Brand drugs appropriate to treat the same condition on a lower cost-sharing 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. We also researched Medicare regulations and reviewed the enrollment data available. The prescriber states that other drugs have been tried for this diagnosis. However, there are no other Brand drugs on a lower cost-sharing 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 the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tradjenta 5 milligram tablets prescribed as 45 tablets per a 90 day supply for diabetes with hyperglycemia. The Part D Plan denied your request for a tiering exception because the plans list of covered drugs did not include any other Brand drugs appropriate to treat the same condition on a lower cost-sharing 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. We also researched Medicare regulations and reviewed the plans enrollment data available. The prescriber states that the enrollee is already on Metformin and Glipizide and will need to continue Tradjenta to optimize his diabetic control. However, the drug is already being provided at the lowest cost-sharing amount allowed by the plan. Tradjenta 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 Reviewers opinion is that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 20 milligram tablets prescribed for the enrollees pulmonary arterial hypertension. 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. The documentation supports the drug was prescribed for the enrollees diagnosis of pulmonary arterial hypertension, which is a medically accepted indication. However, the enrollee does not satisfy the plan's coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria, as the enrollees pulmonary arterial hypertension was not confirmed with a  right heart catheterization.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 Rexulti 4 milligram tablets 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.Rexulti 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

At issue is Hydrocortisone Acetate 25 mg suppository ordered daily for perianal Crohns disease. 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 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 plan denied the request for coverage of Hydrocortisone Acetate 25 mg suppository because the enrollees Part D drug plan cannot cover drugs that are part of the Food and Drug Administration's Drug Efficacy Study Implementation program. These drugs are considered to be less than effective per Food and Drug Administration review.A physician reviewed your appeal and determined that the plan is not required to cover Hydrocortisone Acetate because the drug does not meet the definition of a Part D drug per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tretinoin cream 0.05% to treat follicular cyst of the skin.  The Part D plan did not render a coverage determination. 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 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 Octreotide Acetate 100 micrograms/milliliter solution to treat ateriovenous malformation of small bowel, angiodysplasia of small intestine, and acute gastrointestinal blood loss. The Part D Plan denied the request stating that the provided diagnoses are not medically accepted indications. 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 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 Cyclosporine modified 25 milligram capsules prescribed twice daily for myelodysplastic syndrome. 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. Your medical records show your doctor prescribed cyclosporine modified to treat your myelodysplastic syndrome. 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 Cyclosporine modified.