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

At issue is Envarsus XR 0.75 milligram tablet prescribed twice daily for renal transplant rejection prophylaxis. The Part D plan denied the request.We received the case to perform 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.We determined that the drug is not eligible for Part B coverage. The records show the enrollee received a renal transplant on February 10, 2000. According to Medicare enrollment records, the enrollee was not entitled to Medicare Part A coverage until July 1, 2011. Therefore, the transplant is not considered a Medicare covered transplant and Envarsus XR is not eligible under Medicare Part B. Therefore, the drug can be considered for payment under the Part D benefit.The medical records show the doctor prescribed Envarsus XR for the enrollees renal transplant rejection prophylaxis. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The following citation was referenced in Micromedex, a Medicare approved compendia, and supports the use of this drug for your condition: Envarsus XR in combination with other immunosuppressants is indicated for the prophylaxis of organ rejection in kidney transplant recipients. The records show the enrollee is prescribed Envarsus XR in combination with Cellcept. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Envarsus XR.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gamunex-C 40 grams per 400 milliliter prescribed every 28 days for common variable immunodeficiency. The Part D plan denied the request.We received the case to perform 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 record shows the doctor prescribed Gamunex-C intravenously to treat the enrollees common variable immunodeficiency. However, this drug is eligible for coverage under Medicare Part B. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.We determined that the plan is not required to cover Gamunex-C.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Aduhelm 300 milligram per 3 milliliter solution prescribed for the treatment of Alzheimers disease. The Part D plan your request for coverage.  We received the case to perform 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.Aduhelm is a drug administered via an infusion pump and would be covered under Medicare Part B. Coverage under Part D is excluded for any drug or item for which payment would be available under Part B. We determined that the Medicare Part D plan is not required to cover the requested drug. 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 a request for coverage of Betahistine 16 milligram tablets prescribed for Meniere's disease of the right ear. The Part D plan denied the request. We received the case to perform 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 requested drug is a compounded drug. For a compounded drug to be considered for coverage under Medicare Part D, the compound must contain at least one ingredient that meets the definition of a Part D drug. Betahistine tablets contains two ingredients, which are BETAHISTINE DIHYDROCHLORIDE Powder and AVICEL PH105 PH 105 MICROCRYSTALLINE CELLULOSE. Both of these ingredients are bulk powders. Bulk powders do not satisfy the definition of a Part D drug and are not covered by Part D. Therefore, the Betahistine powder has no ingredients that meet the definition of a Part D drug and is not eligible for coverage under Medicare Part D. 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 Vraylar 1.5 milligram capsule prescribed for major depressive disorder. The Part D plan denied your request. We received the case to perform 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 Vraylar was prescribed to treat the enrollees major depressive disorder. 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.A physician reviewed your appeal and determined that the plan is not required to cover Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Velphoro 500 milligram oral tablet prescribed daily for hyperphosphatemia associated with secondary hyperparathyroidism of renal origin in an enrollee on dialysis. The Part D plan denied your request.We received the case to perform 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to 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 formulary coverage criteria is not supported. A physician reviewed your appeal and determined that the plan is not required to cover Velphoro.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Hydrochlorothiazide 25 milligram for unknown diagnosis. The Part D plan denied your request.We received the case to perform 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 enrollee was given Hydrochorothiazide while in the hospital emergency room. The claim was submitted and processed for an amount that is less than or equal to the required copayment amount. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the out-of-network provider charged. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the copay. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Potassium Chloride 10 MEQ for unknown diagnosis. The Part D plan denied your request.We received the case to perform 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 enrollee was given Potassium Chloride while in the hospital emergency room. The claim was submitted and processed for an amount that is less than or equal to the required copayment amount. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the out-of-network provider charged. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the copay. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Trulicity 0.75 milligram/0.5 milliliter for unknown diagnosis. The Part D plan denied your request.We received the case to perform 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 claim was submitted and processed for an amount that is less than or equal to the required copayment amount. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy or provider charged. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the copay. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ipratropium-Albuterol 0.5-3 milligram/3 nebulizer ampoules, with a quantity of 540 ampoules per 30 days prescribed for chronic obstructive pulmonary disease. The Part D plan denied the request.We received the case to perform 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 Ipratropium-Albuterol is being prescribed for chronic obstructive pulmonary disease. However, this drug may be eligible for coverage under Medicare Part B. Medicare Part B covers this drug, when used with a nebulizer in the home. Medicare Part D cannot pay for drugs that are covered by Medicare Part B.We determined that the plan is not required to cover Ipratropium-Albuterol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Skyrizi 150 milligram per dose subcutaneous syringe kit. We received the case to perform 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. Skyrizi is included in Tier 5 of the Part D plans formulary (list of covered drugs). Tier 5 of the plans formulary is the tier reserved for specialty drugs. The specialty tier is exempt from tiered cost-sharing expectations. Therefore, this drug is not eligible for coverage at a lower-cost tier. A physician reviewed the 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 Diflunisal 500 milligram tablet prescribed for atrial fibrillation, aortic stenosis, dyspnea on exertion and hypertensive heart disease. The Part D plan denied your request. We received the case to perform 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 Diflunisal was prescribed to treat the Enrollees atrial fibrillation, aortic stenosis, dyspnea on exertion and hypertensive heart disease. 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 Diflunisal.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollees physician requested Spiriva Handihaler 18 microgram capsule prescribed daily for other asthma. The Part D plan denied the request. We received the case to perform 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 documentation shows the Enrollees doctor prescribed Spiriva Handihaler to treat other asthma. Without medical records, we cannot determine the requested medication is medically necessary.  A physician reviewed the appeal and determined that the plan is not required to cover Spiriva Handihaler.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Sovaldi 400 milligram tablets prescribed for treatment-experienced chronic Hepatitis C infection, Genotype 1a, with compensated cirrhosis (Child-Pugh A). The Part D plan denied the request for coverage stating that the prior authorization requirements were not met. We received the case to perform 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 enrollee has chronic Hepatitis C infection, genotype 1a, treatment experienced with compensated cirrhosis.  The prescriber provided office notes which state the plan is to treat with 24 weeks of Mavyret + Sofosbuvir + Ribavirin.  The medical records from date of service 6/25/2021 indicate that it is unclear if prior treatment failures were due to noncompliance.  AASLD, a medicare compendium, does not support the use of the requested drug, as prescribed, for 24 weeks. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tramadol Hydrochloride 50 milligram tablet prescribed twice daily as needed for generalized osteoarthritis. The Part D plan denied the Enrollees request.We received the case to perform 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. We asked the prescriber to send us information regarding the Enrollees condition. We also asked for medical records or other documentation to show why the Enrollee needs this medication. The Enrollees medical records show the doctor prescribed Tramadol Hydrochloride to treat the Enrollees generalized osteoarthritis. The Enrollees plan has prior authorization requirements for this drug that must be met 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 the appeal and determined that the plan is not required to cover Tramadol Hydrochloride. The documentation submitted does not support the prior authorization requirements. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Favorable

The Enrollee requested reimbursement for the Shingrix vaccine prescribed for shingles prophylaxis. The Part D plan denied your request. We received the case to perform 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 supports the Enrollee received the Shingrix vaccine as a preventative measure for shingles. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for shingles prophylaxis: Zoster vaccine recombinant, adjuvanted (Shingrix(R)) is indicated in adults 50 years or older for the prevention of herpes zoster infection (shingles). A physician reviewed your appeal and determined that the plan is required to reimburse the Enrollee for the Shingrix vaccine. The vaccine is medically necessary for shingles prevention and we received evidence that you have paid for the vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Adacel TDAP syringe for vaccination. We received the case to perform 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 enrollee was administered the Adacel TDAP vaccine in the physicians office. The claim was submitted and processed for an amount that is less than or equal to the required copayment amount. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the out-of-network provider charged. The plan approved the drug at a price of $118 and paid its share of the the cost. The plan processed the enrollee's copay of $30 and a reimbursement of $88. Therefore, we determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tadalafil 10 milligram oral tablet prescribed daily for benign prostatic hyperplasia with lower urinary tract symptoms. The Part D plan denied your request. We received the case to perform 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. At initial determination the diagnosis of benign prostatic hyperplasia with lower urinary tract symptoms was given. At reconsideration, the diagnosis of pulmonary hypertension was provided. However, the Medicare approved compendia do not support the use of this drug at the requested dosage for either of these conditions. A physician reviewed your appeal and determined that the plan is not required to cover Tadalafil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Synthroid 88 microgram tablets prescribed for post-procedural hypothyroidism secondary to thyroid cancer. The Part D plan denied the request for coverage. We received the case to perform 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.Synthroid is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. During this review, a request was submitted to the prescriber to address the alternative medications included in the plans formulary and to provide supporting medical records. The prescriber did not respond to the request. 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 Abilify Maintena syringes 400 milligram is prescribed for schizoaffective disorder. The Part D plan denied your request. We received the case to perform 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 Abilify was prescribed to treat the Enrollees schizoaffective disorder. 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 Abilify.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Leflunomide 10 milligram oral tablet prescribed daily. The Part D plan denied your request for a tiering exception.We received the case to perform 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. Leflunomide is a generic drug on Tier 3 of the plans formulary. The medical records do not support that all drugs available on lower tiers to treat the Enrollees condition have been tried or deemed contraindicated. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cyclobenzaprine Hydrochloride 10 milligram tablets, 60 tablets per 30 days. The Part D plan denied the request for coverage. We received the case to perform 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 submitted medical records indicate that Cyclobenzaprine Hydrochloride has been prescribed for the management of muscle spasms due to chronic musculoskeletal conditions. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Erythromycin DR 250 milligram tablet prescribed for gastroparesis, constipation and abnormal weight loss. The Part D plan denied your request. We received the case to perform 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 Erythromycin was prescribed to treat the Enrollees gastroparesis, constipation and abnormal weight loss. 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 Erythromycin.