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

You requested Methylphenidate hydrochloride 20 milligram tablets prescribed twice daily. 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 documentation shows the doctor prescribed Methylphenidate hydrochloride to combat the side effects of pain medication in an enrollee with multiple sclerosis and other specific arthropathies, not elsewhere classified. However, 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 Methylphenidate hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Januvia 50 milligram tablets prescribed daily for type 2 diabetes. The Part D plan denied your request for a tiering exception because Januvia is a brand name Tier 3 drug and there are no brand name drugs on lower tiers for your condition. 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 record shows Januvia is being prescribed for type 2 diabetes. The Medicare approved compendia, supports the use of the requested drug for your condition. The plan shows Januvia is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels.Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mavyret (Glecaprevir 100 milligrams/Pibrentasvir 40 milligrams prescribed for Hepatitis C treatment. Your Part D plan denied the drug because the prior authorization requirements were not met. 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 your doctor prescribed Mavyret to treat your Hepatitis C. The Medicare approved compendium does support the use of Mavyret for your condition. However, the medical records and prior authorization do not show you have met the conditions of coverage. A physician reviewed your appeal and determined that the plan is not required to cover Mavyret because you have not met the conditions of coverage per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Adderall 10 milligrams prescribed daily for major depressive disorder, recurrent, severe, without psychotic features. The Part D plan denied your request because the provided diagnosis is not a medically accepted indication. We received an expedited reconsideration request.  We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Adderall 10 milligrams daily to treat your major depressive disorder, recurrent, severe, without psychotic features. 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 Adderall 10 milligrams because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ranexa 1000 milligrams prescribed twice daily for ischemic cardiomyopathy. The Part D Plan denied your request for a tiering exception. We received an expedited 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.Ranexa is a brand drug on Tier 4 of the plans formulary. The prescriber statement shows the enrollee was being treated for ischemic cardiomyopathy and there is no alternative to Ranexa. However, the plans formulary includes medications which are the same class as Renaxa on a lower tier. The physician did not address why these medications would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Ranexa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine Ointment 5% prescribed for pain related to polyneuropathy, spondylosis without myelopathy or radiculopathy, pain in the right knee, other postherpetic nervous system involvement, post herpetic neuralgia and arthropathy of cervical facet joint. The Part D plan denied the request. 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. Medicare approved compendia does not support the use of Lidocaine Ointment for the diagnoses submitted. Therefore, it is ineligible for coverage under Medicare Part D.   A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine Ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Tradjenta 5 milligram tablets prescribed daily for type 2 diabetes. The Part D plan denied your request for a tiering exception because Tradjenta is a brand name Tier 3 drug and there are no brand name drugs on lower tiers for your condition. 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 record shows Tradjenta is being prescribed for type 2 diabetes. The Medicare approved compendia, supports the use of the requested drug for your condition. The plan shows Tradjenta is a brand name Tier 3 drug. There are no brand name drugs of the same type on the lower cost sharing levels.Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tier exception for Toviaz ER 4 milligram tablets prescribed daily for unspecified urinary incontinence. The Part D plan denied your request for a tiering exception because Toviaz ER is a brand name Tier 4 drug and there are no brand name drugs on lower tiers for your condition. 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 plan shows Toviaz ER is a brand name Tier 4 drug. There are no brand name drugs of the same type on the lower cost sharing levels.Therefore, the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablets prescribed as directed for hepatic encephalopathy. The Part D plan denied your request for a tiering exception because the drug you requested is in the specialty tier; drugs placed in the specialty tier are not eligible for tiering exceptions. 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. This drug is being provided by the plan at the cost sharing level of the Specialty Tier. Specialty Tier drugs are not available for a tiering exception per Medicare rules. 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 Xifaxan 550 milligram tablets because a tiering exception cannot be granted for a drug on the specialty tier of this plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humalog 100 units per milliliter prescribed for type 2 diabetes with hyperglycemia. 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 prescriber has not indicated why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. 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

You requested a formulary exception for Welchol 625 milligram tablet prescribed daily for diarrhea, unspecified. 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 Welchol for diarrhea, unspecified.In review of the Medicare approved compendia, unspecified diarrhea is not a medically accepted indication for Welchol. Therefore, it does not meet the definition of a Part D drug and a formulary exception cannot be granted. The plan is not required to cover the Welchol at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for and unknown diagnosis. 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. Additional documentation was requested but not received.A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine 5% patch. There is insufficient documentation to determine if the medicine is medically necessary.  Additionally, without documentation, it cannot be determined if prior authorization criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Topamax 50 milligram tablets to treat bipolar 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 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.A physician reviewed your appeal and determined that the plan is not required to cover Topamax.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vemlidy 25 milligrams prescribed daily for chronic hepatitis B virus without compensated liver disease. 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 Vemlidy to treat the enrollees chronic hepatitis B virus liver disease. Although the prescriber statement indicated the enrollee's liver disease is without compensation, the laboratory reports submitted have normal liver function values. The laboratory reports support a diagnosis of chronic hepatitis B with compensated liver disease. The Medicare approved compendia support the use of this drug for this condition. The prior authorization criteria are met.A physician reviewed your appeal and determined that the plan is required to cover Vemlidy.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Erythrocin 250 milligrams for the treatment of unspecified gastroparesis. 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 Erythrocin to treat unspecified gastroparesis in an adult. However, the Medicare approved compendia do not support the use of Erythrocin for this condition. A tiering exception cannot be given for a drug without a medically approved indication for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Erythrocin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sandostatin 20 milligrams to treat gastrointestinal bleeding related to arteriovenous malformations of the small bowel. The Part D plan denied your request because the provided diagnosis does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request.  We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. 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 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 drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Octagam 20 grams/200 milliliters to treat non-familial hypogammaglobinemia and other complications of lung transplant. 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 Physicians Reviewer determined that the plan is not required to cover Octagam.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil Citrate 20 milligram tablets prescribed for Sjogrens syndrome. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization requirements be met 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 information submitted at the reconsideration level. The medical records show the physician prescribed Sildenafil Citrate to treat the enrollees condition. However, the Medicare approved compendia do not support the use of this drug for the condition. The plan requires a diagnosis of pulmonary arterial hypertension before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria. The medical records do not support pulmonary arterial hypertension.A physician reviewed your appeal and determined that the plan is not required to cover Sildenafil Citrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 250 milligram tablets prescribed twice daily following a heart transplant. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received an expedited reconsideration request.We performed an independent and de novo review. To make our decision, we read 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 Mycophenolate mofetil 250 milligram tablets after a heart transplant. The record shows that you received a heart transplant on March 28, 2014. According to Medicare enrollment records, you were entitled to Medicare Part A coverage on November 1, 2012. Medicare law excludes coverage for any drug under the Part D program for which payment would be available under Parts A or B. Coverage is available under Medicare Part B for prescription drugs used in immunosuppressive therapy furnished to an enrollee that was covered under Medicare Part A at the time of the transplant. You were covered under Medicare Part A at the time of the transplant. 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 Mycophenolate Mofetil 250 milligram tablets because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit.You may wish to submit a request for Mycophenolate Mofetil 250 milligram tablets to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Caplyta 42 milligram capsules prescribed as directed for unspecified psychosis not due to a substance or known physiological condition. 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 documentation shows the doctor prescribed Caplyta for an enrollee with unspecified psychosis not due to a substance or known physiological condition, intermittent explosive disorder, and mild intellectual disabilities. However, the Medicare approved compendia do not support the use of this drug for the enrollees conditions.A physician reviewed your appeal and determined that the plan is not required to cover Caplyta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sirolimus 1 milligram tablet to prevent rejection in a heart transplant enrollee. The Part D plan denied your request because the enrollee was eligible for Medicare Part B coverage at the time of transplant. 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. The record shows the enrollee received a heart transplant on November 30, 2018, which was covered under Medicare Part A. Medicare rules state that drugs used to prevent transplant rejection are covered under Medicare Part B. Therefore, Sirolimus is eligible under Medicare Part B. We determined the Part D plan is not required to cover Sirolimus. Please consider submitting this request to Medicare Part B. 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 Aspirin-Dipyridamole ER 25-200 milligram extended release 12-hour capsules prescribed due to a history of stroke. The Part D Plan denied your request for a tiering exception because  the submitted documentation did not explain why the plans alternative drugs in lower tiers would not work just as well. 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. Aspirin-Dipyridamole ER is a generic drug on Tier 4 of the plans formulary. The submitted documentation does not address why the generic drugs of the same type on the lower tiers of the plans formulary have been tried and failed, or are contraindicated. Therefore, a lower cost tiering exception cannot be granted. A physician reviewed your appeal and determined that the Aspirin-Dipyridamole ER is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Glumetza prescribed for an unknown diagnosis. We received an expedited reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. The prescriber states the enrollee needs the medicine for continued therapy; however, no medical documentation was submitted to support the enrollees diagnosis and other medications on plan formulary that were tried and failed.  A physician reviewed your appeal and determined that the plan is not required to cover the Glumetza. There is insufficient documentation to determine if the medicine is medically necessary.