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

At issue is Dexilant DR 60 milligram capsules to treat gastroesophageal reflux 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 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 coverage for Droxidopa 100 milligram capsule to treat orthostatic hypotension. 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 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 that must be met before coverage will be provided. The submitted medical records do not confirm that the plans requirements for coverage have been satisfied. 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 Topiramate 50 milligram and 100 milligram tablets to treat major depressive disorder, recurrent episode, moderate. 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: Unfavorable

At issue is a formulary exception request for Spiriva Handihaler 18 microgram inhalation capsule. 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. Of note, formulary exception criteria have also not been met as there is no indication that all of the drugs on the plan's formulary have been tried and failed or are contraindicated.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 Carbidopa-Levodopa ER (extended release) 25/100 milligram tablet to treat 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 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 coverage for Vonjo 100 milligram capsule to treat myelofibrosis. 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 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 that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. 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 Triazolam 0.25 milligram tablet. The Part D plan auto-forwarded the case to us for review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Triazolam 0.25 milligram tablet is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost-sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

Clobetasol 0.05 percent ointment was requested to treat the enrollees condition. 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.A request was submitted to the prescriber to provide a diagnosis, to address the nonformulary exception criteria and to provide supporting medical records. A reply from the prescriber was not received. Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xiaflex 0.9 milligram solution reconstituted to treat Peyronie's disease with unspecified plaque and curvature severity. 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 this diagnosis with the compendia supported citation needed for Peyronie's disease. However, we did not receive the requested information. Of note, formulary exception cannot be addressed at this time as drug has not been approved.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 Singulair 10 milligram tablet. 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.A request was submitted to the prescriber to provide a diagnosis, to clarify the medical history, to address the nonformulary exception criteria, and to provide supporting medical records. A reply from the prescriber was not received. The submitted documentation does not include medical records or evidence of the medical necessity of the prescribed drug. 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 a tiering exception request for Brilinta 60 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.Brilinta 60 milligram tablet is a brand drug on Tier 4 of the plans formulary. We requested additional information from the prescriber. Specifically, we requested a prescriber statement and medical records to support all lower-tier drugs to treat the same conditions were tried and failed or were contraindicated. However, we did not receive the requested information.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 Flovent Diskus to treat an unspecified diagnosis. 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill. Therefore, we determined the enrollee is responsible for the additional copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prednisolone Sodium Phosphate 1 percent, Moxifloxacin Hydrochloride 0.5 percent, Bromfenac Sodium 0.075 percent ophthalmic solution compound prescribed for after cataract surgery. 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. This includes the case file from the plan, and any information submitted at the reconsideration level.Drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The requested compound is consistent of bulk powder ingredients and is excluded from coverage under Part D and not eligible for reimbursement. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Synthroid 25 microgram 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.Synthroid 25 microgram tablet is a brand drug on Tier 3 of the plans formulary. The prescriber has not indicated if all alternatives, 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 Rabavert Injection. The Part D plan denied the request but indicated it was approved for the total cost of $1635 through the Medicare Part B benefit.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 submitted documentation shows the requested drug is being administered as an injection to treat or prevent an injury due to direct exposure to a disease or condition. Therefore, this drug was appropriately approved through Part B and would not be eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Chondroitin Sulfate Sodium 100 percent powder as part of a compound drug. 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 National Drug Code provided for Chondroitin Sulfate Sodium is not listed with the Food and Drug Administration as a valid code. Therefore, we determined the 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 Lotenprednol Etabonate as part of a compound drug. 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. We also researched Medicare regulations and Medicare approved compendia.The Nation Drug Code submitted for this drug shows this is a bulk powder. Bulk powders do not satisfy the definition of a Part D drug. Therefore, the drug is excluded from coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol 90 microgram oral inhaler prescribed for an unspecified diagnosis. The Part D plan denied the request for reimbursement.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 rules state that coordination of benefits between Part D and Veterans Affairs is not allowed. Medicare records show the enrollee is eligible to receive Veterans Affairs prescription drug benefits and Part D benefits. However, both benefits cannot be used for a single prescription. In this case, the enrollee requested reimbursement for drugs already covered and paid for by a Veteran Affairs benefit. Therefore, we determined that the Part D plan is not required to provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cetirizine Hydrochloride 10 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the request for reimbursement.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 rules state that coordination of benefits between Part D and Veterans Affairs is not allowed. Medicare records show the enrollee is eligible to receive Veterans Affairs prescription drug benefits and Part D benefits. However, both benefits cannot be used for a single prescription. In this case, the enrollee requested reimbursement for drugs already covered and paid for by a Veteran Affairs benefit. Therefore, we determined that the Part D plan is not required to provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Chlorthalidone 50 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the request for reimbursement.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 rules state that coordination of benefits between Part D and Veterans Affairs is not allowed. Medicare records show the enrollee is eligible to receive Veterans Affairs prescription drug benefits and Part D benefits. However, both benefits cannot be used for a single prescription. In this case, the enrollee requested reimbursement for drugs already covered and paid for by a Veteran Affairs benefit. Therefore, we determined that the Part D plan is not required to provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clotrimazole 1 percent cream prescribed for an unspecified diagnosis. The Part D plan denied the request for reimbursement.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 rules state that coordination of benefits between Part D and Veterans Affairs is not allowed. Medicare records show the enrollee is eligible to receive Veterans Affairs prescription drug benefits and Part D benefits. However, both benefits cannot be used for a single prescription. In this case, the enrollee requested reimbursement for drugs already covered and paid for by a Veteran Affairs benefit. Therefore, we determined that the Part D plan is not required to provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluticasone Propionate 50 microgram nasal inhaler prescribed for an unspecified diagnosis. The Part D plan denied the request for reimbursement.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 rules state that coordination of benefits between Part D and Veterans Affairs is not allowed. Medicare records show the enrollee is eligible to receive Veterans Affairs prescription drug benefits and Part D benefits. However, both benefits cannot be used for a single prescription. In this case, the enrollee requested reimbursement for drugs already covered and paid for by a Veteran Affairs benefit. Therefore, we determined that the Part D plan is not required to provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gabapentin 300 milligram capsule prescribed for an unspecified diagnosis. The Part D plan denied the request for reimbursement.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 rules state that coordination of benefits between Part D and Veterans Affairs is not allowed. Medicare records show the enrollee is eligible to receive Veterans Affairs prescription drug benefits and Part D benefits. However, both benefits cannot be used for a single prescription. In this case, the enrollee requested reimbursement for drugs already covered and paid for by a Veteran Affairs benefit. Therefore, we determined that the Part D plan is not required to provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent patch prescribed for an unspecified diagnosis. The Part D plan denied the request for reimbursement.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 rules state that coordination of benefits between Part D and Veterans Affairs is not allowed. Medicare records show the enrollee is eligible to receive Veterans Affairs prescription drug benefits and Part D benefits. However, both benefits cannot be used for a single prescription. In this case, the enrollee requested reimbursement for drugs already covered and paid for by a Veteran Affairs benefit. Therefore, we determined that the Part D plan is not required to provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Meclizine Hydrochloride 25 milligram chew tablet prescribed for an unspecified diagnosis. The Part D plan denied the request for reimbursement.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 rules state that coordination of benefits between Part D and Veterans Affairs is not allowed. Medicare records show the enrollee is eligible to receive Veterans Affairs prescription drug benefits and Part D benefits. However, both benefits cannot be used for a single prescription. In this case, the enrollee requested reimbursement for drugs already covered and paid for by a Veteran Affairs benefit. Therefore, we determined that the Part D plan is not required to provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metoprolol Succinate 25 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the request for reimbursement.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 rules state that coordination of benefits between Part D and Veterans Affairs is not allowed. Medicare records show the enrollee is eligible to receive Veterans Affairs prescription drug benefits and Part D benefits. However, both benefits cannot be used for a single prescription. In this case, the enrollee requested reimbursement for drugs already covered and paid for by a Veteran Affairs benefit. Therefore, we determined that the Part D plan is not required to provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Miconazole Nitrate 2 percent topical powder prescribed for an unspecified diagnosis. The Part D plan denied the request for reimbursement.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 rules state that coordination of benefits between Part D and Veterans Affairs is not allowed. Medicare records show the enrollee is eligible to receive Veterans Affairs prescription drug benefits and Part D benefits. However, both benefits cannot be used for a single prescription. In this case, the enrollee requested reimbursement for drugs already covered and paid for by a Veteran Affairs benefit. Therefore, we determined that the Part D plan is not required to provide reimbursement for the requested drug.