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

At issue is Motegrity 2-milligram tablets. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. At reconsideration a diagnosis of chronic idiopathic constipation was given. However, the documentation provided by the prescriber does not support this diagnosis. We are not able to determine whether the requested drug(s) was prescribed for a medically accepted indication. Therefore, the drug(s) is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xarelto 20 milligram tablet used for the prophylaxis of cerebrovascular accidents or thromboembolism in atrial fibrillation. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Xarelto 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 diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexletol 180-milligram tablets to treat unspecified hyperlipidemia. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including 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 diagnosis. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hizentra intravenous infusion for use in the enrollee's home. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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 Vemlidy 25-milligram tablets to treat chronic hepatitis B infection. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. 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. In this case, the documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron Hydrochloride 4-milligram tablets to treat nausea and vomiting. The case was auto-forwarded by the plan. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including 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 diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 200-milligram tablets to treat other fatigue; Parkinson's 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 reviewed all documentation submitted, including 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 diagnosis. On appeal, the prescriber indicated the enrollee also has a diagnosis of depression; however, there were no medical records submitted to support this diagnosis. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Vimpat 100 milligram tablet. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Vimpat is a brand drug on Tier 4 of the plans formulary. The submitted evidence has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ambisome 50-milligram intravenous solution. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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 Tadalafil 20-milligram tablets to treat erectile dysfunction. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other diagnoses for which the drug is not Food and Drug Administration (FDA) approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promacta 25-milligram tablets. The Part D plan denied the request.We received the submitted documentation to perform an independent and de novo review.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acetaminophen 500-milligram capsule prescribed for unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation indicates the enrollee was in a skilled nursing facility at the time the drug was filled. According to Medicare rules, Part A pays for drugs received by an enrollee in a skilled nursing facility setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. 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 Eliquis 5-milligram tablet prescribed for unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation indicates the enrollee was in a skilled nursing facility at the time the drug was filled. According to Medicare rules, Part A pays for drugs received by an enrollee in a skilled nursing facility setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. 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 Finasteride 5-milligram tablet prescribed for unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation indicates the enrollee was in a skilled nursing facility at the time the drug was filled. According to Medicare rules, Part A pays for drugs received by an enrollee in a skilled nursing facility setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. 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 Lorazepam 0.5-milligram tablet prescribed for unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation indicates the enrollee was in a skilled nursing facility at the time the drug was filled. According to Medicare rules, Part A pays for drugs received by an enrollee in a skilled nursing facility setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. 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 Lorazepam 2-milligram tablet prescribed for unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation indicates the enrollee was in a skilled nursing facility at the time the drug was filled. According to Medicare rules, Part A pays for drugs received by an enrollee in a skilled nursing facility setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. 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 Memantine Hydrochloride extended release 14-milligram capsule prescribed for unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation indicates the enrollee was in a skilled nursing facility at the time the drug was filled. According to Medicare rules, Part A pays for drugs received by an enrollee in a skilled nursing facility setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. 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 Risperidone 1-milligram tablet prescribed for unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation indicates the enrollee was in a skilled nursing facility at the time the drug was filled. According to Medicare rules, Part A pays for drugs received by an enrollee in a skilled nursing facility setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. 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 Rivastigmine 1.5-milligram capsule prescribed for unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation indicates the enrollee was in a skilled nursing facility at the time the drug was filled. According to Medicare rules, Part A pays for drugs received by an enrollee in a skilled nursing facility setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. 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 Sertraline Hydrochloride 100-milligram tablet prescribed for unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation indicates the enrollee was in a skilled nursing facility at the time the drug was filled. According to Medicare rules, Part A pays for drugs received by an enrollee in a skilled nursing facility setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. 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 Sotalol 80-milligram tablet prescribed for unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation indicates the enrollee was in a skilled nursing facility at the time the drug was filled. According to Medicare rules, Part A pays for drugs received by an enrollee in a skilled nursing facility setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. 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 Tamsulosin 0.4-milligram capsule prescribed for unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation indicates the enrollee was in a skilled nursing facility at the time the drug was filled. According to Medicare rules, Part A pays for drugs received by an enrollee in a skilled nursing facility setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. 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 Trazodone 100-milligram tablet prescribed for unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation indicates the enrollee was in a skilled nursing facility at the time the drug was filled. According to Medicare rules, Part A pays for drugs received by an enrollee in a skilled nursing facility setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. 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 Privigen 5-gram/50-milliliter intravenous infusion. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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 Intrarosa 6.5-milligram vaginal insert. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed or were contraindicated. However, we did not receive the requested information.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 10-milligram capsules to treat chronic pain due to cancer and seizure control. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee has satisfied the plans prior authorization coverage criteria.However, we did not receive the requested information.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 diagnosis. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Amoxicillin 500-milligram tablets. The Part D plan denied the request.We received the submitted documentation to perform an independent and de novo review.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. A tiering exception cannot be allowed for a drug that has not been approved for coverage.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.