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

At issue is Alosetron Hydrochloride 1-milligram tablet to treat irritable bowel syndrome with diarrhea. 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(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: Favorable

At issue is BD Pen Needle/Mini/Ultra-Fine/31-gauge by 5-millimeters, 100-units. 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 limits the amount of needles to 100-needles per 30-days. The requested quantity is within the plans allowed quantity limit. The plan is required to reimburse you for the cost of the BD Pen Needle/Mini/Ultra-Fine/31-gauge by 5-millimeters, 100-units. Fill date was within 2 days of plan's proposed fill date.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage and the plan is required to reimburse you for the cost of the BD Pen Needles/Mini/Ultra-Fine/31-gauge by 5-millimeters, 100-units .
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Belsomra 20-milligram tablet to treat insomnia. 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.Belsomra is a brand drug on Tier 4 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 Buprenorphine Hydrochloride 8-milligram sublingual tablets 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 use of the requested drug to treat the provided condition 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 Ascorbic Acid (Vitamin C) 500-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.The documentation shows the enrollee received Ascorbic Acid (Vitamin C) 500-milligram tablets on January 30, and 31, 2021, and February 1, 2, and 3, 2021. However, there is no supporting documentation indicating the enrollee paid for the requested drug. In addition, drugs prescribed for use as vitamins and minerals 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 Cholecalciferol (Vitamin D3) 5,000-international units. 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 also shows the enrollee received Cholecalciferol (Vitamin D3) 5,000-international units on February 2, and 3, 2021. However, there is no supporting documentation indicating the enrollee paid for the requested drug. In addition, drugs prescribed for use as vitamins and minerals 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 Ecotrin 81-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.The documentation shows the enrollee received Ecotrin 81-milligram tablets on January 31, 2021, and February 2, and 3, 2021. However, there is no supporting documentation indicating the enrollee paid for the requested drug. In addition, drugs prescribed that are available over the counter 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 Hydrochlorthiazide 25-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.The documentation shows the enrollee received Hydrochlorthiazide 25-milligram tablets on February 1, 2, and 3, 2021. However, there is no supporting documentation indicating the enrollee paid for the requested drug. Therefore, the plan is not required to cover or reimburse for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Potassium Chloride 20-milliequivalents per 15-milliliters oral liquid. 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 shows the enrollee received Potassium Chloride 20-milliequivalents per 15-milliliters oral liquid on January 30, 2021. However, there is no supporting documentation indicating the enrollee paid for the requested drug. In addition, Potassium Chloride 20-milliequivalents per 15-milliliters oral liquid is not on the plans formulary. Therefore, the plan is not required to cover or reimburse for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Multivitamin tablets or capsules. 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 shows the enrollee received Multivitamin tablets or capsules on January 31, 2021, and February 1, and 3, 2021. However, there is no supporting documentation indicating the enrollee paid for the requested drug. In addition, drugs prescribed for use as vitamins and minerals 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 Oxycontin 20-milligrams 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.The documentation shows the enrollee received Oxycontin 20-milligrams tablets on February 1, 2, and 3, 2021. However, there is no supporting documentation indicating the enrollee paid for the requested drug. Therefore, the plan is not required to cover or reimburse for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Protonix 40-milligram controlled-release 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.The documentation shows the enrollee received Protonix 49-milligram controlled-release tablets on January 31, 2021, and February 1, and 2, 2021. However, there is no supporting documentation indicating the enrollee paid for the requested drug. Therefore, the plan is not required to cover or reimburse for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Singulair 10-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.The documentation shows the enrollee received Singulair 10-milligram tablets on January 31, 2021, and February 1, 2, and 3, 2021. However, there is no supporting documentation indicating the enrollee paid for the requested drug. Therefore, the plan is not required to cover or reimburse you for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tylenol 325-milligram caplets. 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 shows the enrollee received Tylenol 325-milligram caplets on January 31, 2021, and February 1, and 2, 2021. However, there is no supporting documentation indicating the enrollee paid for the requested drug. In addition, drugs prescribed that are available over the counter 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 Vibramycin 100-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.The documentation shows the enrollee received Vibramycin 100-milligram tablets on January 30, 2021. However, there is no supporting documentation indicating the enrollee paid for the requested drug. Therefore, the plan is not required to cover or reimburse for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vimpat 50-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.The documentation shows the enrollee received Vimpat 50-milligram tablets on January 30, and 31, 2021, and February 1, 2, and 3, 20121. However, there is no supporting documentation indicating the enrollee paid for the requested drug. Therefore, the plan is not required to cover or reimburse for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vitamin D 5,000-international unit capsules. 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 shows the enrollee received Vitamin D 5,000-international unit capsules on February 2, and 3, 2021. However, there is no supporting documentation indicating the enrollee paid for the requested drug. In addition, drugs prescribed for use as vitamins and minerals 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 Xanax 0.25-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.The documentation shows the enrollee received Xanax 0.25-milligram tablets on January 31, 2021, and February 1, and 2, 2021. However, there is no supporting documentation indicating the enrollee paid for the requested drug. In addition, Xanax 0.25-milligram tablets is not on the plans formulary. Therefore, the plan is not required to cover or reimburse for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zestril Prinivil 10-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.The documentation shows the enrollee received Zestril Prinivil 10-milligram tablets on February 1, 2, and 3, 2021. However, there is no supporting documentation indicating the enrollee paid for the requested drug. In addition, Zestril Prinivil 10-milligram tablets is not on the plans formulary. Therefore, the plan is not required to cover or reimburse for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zinc Sulfate 220-milligram capsules. 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 shows the enrollee received Zinc Sulfate 220-milligram capsules on January 31, 2021, and February 1, 2021. However, there is no supporting documentation indicating the enrollee paid for the requested drug. In addition, drugs prescribed for use as vitamins and minerals 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 a tiering exception request for Eliquis 5-milligram tablet to treat 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 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 Buprenorphine 5-microgram per hour weekly transdermal patches to treat chronic pain syndrome. 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. At reconsideration, the prescriber has noted that the formulary alternative suggested by the plan, Tramadol, is contraindicated because the enrollee is taking Cymbalta and there is an increased risk for serotonin syndrome when the two drugs are used concurrently. However, this is not a contraindication; it is a precaution. Furthermore, the requested drug, Buprenorphine, has the same precaution when used concurrently with Cymbalta. There are additional formulary alternatives to treat the enrollee's condition on the formulary.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 Tresiba Flex touch 100 unit ml vial to treat type 2 diabetes mellitus without complications. 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.Tresiba Flex touch 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 Wegovy 0.5 milligram/0.5 milliliter solution to treat weight loss. 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.Drugs prescribed for the treatment of weight loss are excluded from coverage. Therefore, this drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Potassium Citrate/Citric Acid 1100/334-milligrams per 5-milliliters Solution for the prevention of kidney stones. 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 alternative drugs provided on the plans formulary list 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 Duaklir Pressair 400-12-microgram Inhaler to treat 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 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 alternative drugs provided on the plans formulary list 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: Favorable

At issue is Trulicity 1.5-milligram/0.5-milliliter injection solution to treat type II diabetes mellitus without complications. 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 step therapy requirements that must be met prior to approval of the biologic at issue. The submitted documentation includes medical records that support the enrollee has previously been treated with Metformin and had an adverse reaction. The plan's step therapy requirements have been met. A physician reviewed the appeal and determined that the requested biologic is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tremfya 100-milligram/milliliter pen injectors to treat psoriasis vulgaris. 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 drug at issue is not on the plans formulary. The prescriber provided patient specific clinical rationale supported by documentation, indicating why the formulary alternatives, required by the plan, would likely not be as effective as the requested drug for this diagnosis, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is medically necessary.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 Inqovi 100-milligram /35-milligram tablet to treat acute myeloblastic leukemia. 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 Cycloobenzaprine HCL 10-milligram tablet to treat muscle spasm. 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(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.