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

At issue is Repatha Sureclick 140 milligram per milliliter solution auto-injector to treat familial hypercholesterolemia. 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 a tiering exception request for Eliquis 5 milligram tablet for prophylaxis of thromboembolism in an enrollee with 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.Eliquis 5 milligram tablet is a brand drug on Tier 3 of the plans formulary. There are no 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 Octagam 10 percent vial to treat chronic inflammatory demyelinating polyneuropathy. 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 Vraylar 1.5 milligram capsule to treat major depression, adjunct treatment. 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 plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Mycophenolate 500 milligram tablet to treat dermatomyositis complicated by interstitial lung disease, antisynthetase spectrum. 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 documentation satisfies the plans coverage criteria. Additional documents were submitted at reconsideration. The diagnosis is dermatomyositis complicated by interstitial lung disease, which is a medically accepted indication in Medicare approved compendia and meets prior authorization criteria.  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 2.5 milligram tablet 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 Aranesp 25 microgram/0.42 milliliter prefilled syringe to treat chronic blood loss anemia and acute on chronic gastrointestinal bleeding. 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 a tiering exception request for Fentanyl 12 microgram per hour patch to treat chronic pain. 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. Fentanyl 12 microgram per hour patch is a generic drug on Tier 4 of the plans formulary. The prescriber 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 Hetlioz 20 milligram capsule to treat circadian rhythm sleep disorder, free-running type (non-24-hour sleep-wake type). 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.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 plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.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 Nucynta ER (extended release) 100 milligram tablet to treat chronic pain. 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 Morphine Sulfate 30 milligram extended-release tablet to treat chronic low back pain with radiculopathy, lumbar region. 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 plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.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 Lumakras 120 milligram tablets to treat metastatic mucinous adenocarcinoma with large cell neurioendocrine features. 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. Medicare-approved compendia do not contain any citations to support the use of the requested drug as prescribed, for treatment of the noted diagnosis. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.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 Albuterol Hydrofluoroalkane (HFA) 90 microgram inhaler prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request.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 shows the enrollee is requesting reimbursement for Albuterol Hydrofluoroalkane (HFA), based on pharmacy prescription history for the out-of-pocket purchase. The plan's Evidence of Coverage states, that if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the documentation does not include the dosage, days supply, and National Drug Code (NDC) of the requested drug. Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azithromycin 250 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request.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 shows the enrollee is requesting reimbursement for Azithromycin, based on pharmacy prescription history for the out-of-pocket purchase. The plan's Evidence of Coverage states, that if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the documentation does not include the dosage, days supply, and National Drug Code (NDC) of the requested drug. Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine 5 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request.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 shows the enrollee is requesting reimbursement for Cyclobenzaprine, based on pharmacy prescription history for the out-of-pocket purchase. The plan's Evidence of Coverage states, that if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the documentation does not include the dosage, days supply, and National Drug Code (NDC) of the requested drug. Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Doxazosin Mesylate 1 gram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request.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 shows the enrollee is requesting reimbursement for Doxazosin Mesylate, based on pharmacy prescription history for the out-of-pocket purchase. The plan's Evidence of Coverage states, that if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the documentation does not include the dosage, days supply, and National Drug Code (NDC) of the requested drug. Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Doxazosin Mesylate 1 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request.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 shows the enrollee is requesting reimbursement for Doxazosin Mesylate, based on pharmacy prescription history for the out-of-pocket purchase. The plan's Evidence of Coverage states, that if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the documentation does not include the dosage, days supply, and National Drug Code (NDC) of the requested drug. Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Escitalopram 20 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request.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 shows the enrollee is requesting reimbursement for Escitalopram, based on pharmacy prescription history for the out-of-pocket purchase. The plan's Evidence of Coverage states, that if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the documentation does not include the dosage, days supply, and National Drug Code (NDC) of the requested drug. Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Finasteride 5 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request.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 shows the enrollee is requesting reimbursement for Finasteride, based on pharmacy prescription history for the out-of-pocket purchase. The plan's Evidence of Coverage states, that if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the documentation does not include the dosage, days supply, and National Drug Code (NDC) of the requested drug. Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluticasone/Salmeterol 250/50 inhaler prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request.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 shows the enrollee is requesting reimbursement for Fluticasone/Salmeterol, based on pharmacy prescription history for the out-of-pocket purchase. The plan's Evidence of Coverage states, that if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the documentation does not include the dosage, days supply, and National Drug Code (NDC) of the requested drug. Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Furosemide 20 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request.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 shows the enrollee is requesting reimbursement for Furosemide, based on pharmacy prescription history for the out-of-pocket purchase. The plan's Evidence of Coverage states, that if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the documentation does not include the dosage, days supply, and National Drug Code (NDC) of the requested drug. Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Klor-Con 20 milliequivalent packet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request.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 shows the enrollee is requesting reimbursement for Klor-Con, based on pharmacy prescription history for the out-of-pocket purchase. The plan's Evidence of Coverage states, that if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the documentation does not include the dosage, days supply, and National Drug Code (NDC) of the requested drug. Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lisinopril/Hydrochlorothiazide 20/25 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request.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 shows the enrollee is requesting reimbursement for Lisinopril/Hydrochlorothiazide, based on pharmacy prescription history for the out-of-pocket purchase. The plan's Evidence of Coverage states, that if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the documentation does not include the dosage, days supply, and National Drug Code (NDC) of the requested drug. Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metoprolol Succinate extended release 100 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request.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 shows the enrollee is requesting reimbursement for Metoprolol Succinate, based on pharmacy prescription history for the out-of-pocket purchase. The plan's Evidence of Coverage states, that if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the documentation does not include the dosage, days supply, and National Drug Code (NDC) of the requested drug. Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nitrofurantoin Monohydrate Microcrystalline 100 milligram crystals prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request.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 shows the enrollee is requesting reimbursement for Nitrofurantoin Monohydrate Microcrystalline, based on pharmacy prescription history for the out-of-pocket purchase. The plan's Evidence of Coverage states, that if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the documentation does not include the dosage, days supply, and National Drug Code (NDC) of the requested drug. Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone/Acetaminophen 5/325 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request.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 shows the enrollee is requesting reimbursement for Oxycodone/Acetaminophen, based on pharmacy prescription history for the out-of-pocket purchase. The plan's Evidence of Coverage states, that if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the documentation does not include the dosage, days supply, and National Drug Code (NDC) of the requested drug. Therefore, the reimbursement criteria are not met.