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

At issue is coverage for Revlimid 20 milligram capsule, 28 capsules per 2 days. The Part D plan denied the request for an exception to the plans quantity limit for the drug, which is 21 capsules per 28 days, because the drug was not being prescribed to treat a medically accepted indication.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 medical records submitted at reconsideration clarify that the quantity of Revlimid capsules being requested is 28 capsule per 28 days, 1 capsule to be taken daily. However, this amount still exceeds the plans quantity limit for the drug, which is 21 capsules per 28 days. The submitted documentation indicates that the requested drug has been prescribed to treat discoid lupus erythematosus (with underling systemic lupus erythematosus) and rheumatoid arthritis. However, the noted conditions are off-label uses for the requested drug. The Medicare-approved compendia do not contain any citations to support the use of the requested drug for the treatment of these conditions. Therefore, the drug is being prescribed for non-medically accepted indications. Since the drug is being prescribed for non-medically accepted indications, an exception to the plans quantity limit is not supported. A physician reviewed the appeal and determined that the requested drug at the requested amount is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate Hydrochloride ER (extended release) 40 milligram capsule to treat attention deficit hyperactivity disorder. 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 and failed or must be 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 Jardiance 25 milligram tablet to treat type 2 diabetes. 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. Jardiance 25 milligram tablet 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 a tiering exception request for Ozempic 0.25 milligram or 0.5 milligram per dose pen injector to treat type 2 diabetes mellitus. 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.Ozempic 0.25 milligram or 0.5 milligram per dose pen injector 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 Cyclobenzaprine Hydrochloride 5 milligram tablet to treat lumbar radiculopathy and neuropathic 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.At reconsideration a diagnosis of muscle spasm was given. However, there was no documentation provided by the prescriber to support this diagnosis. In addition, this drug is only covered for acute muscle spasms not chronic. 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 coverage for Igalmi 120 microgram sublingual film to treat autonomic dysfunction and hypertension. 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 noted conditions are off-label uses for the requested drug. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. Therefore, the drug is being prescribed for non-medically accepted indications.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 Orencia 125 milligram per milliliter syringe to treat rheumatoid arthritis. 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 Repatha 140 milligram per milliliter solution. The Part D plan denied the request.We received the submitted documentation to perform an independent and de novo review.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 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 Hetlioz 20 milligram capsule to treat circadian rhythm sleep disorder, free running type. 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 to address the prior authorization 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 Hetlioz 20 milligram capsule to treat non 24 hour sleep wake disorder. 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 to address the prior authorization 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 coverage for Relistor 150 milligram tablet to treat opioid-induced constipation. 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 documentation submitted.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that all formulary alternatives were tried and failed, or were contraindicated. The prescriber did not respond to the request.Relistor 150 milligram tablet is not on the plans formulary. In order to grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the documentation does not support why the plans formulary alternative drugs to treat the enrollees condition would likely not be as effective and/or would likely cause adverse reactions or other harm. Furthermore, the available documentation does not indicate that the enrollee has tried and failed the formulary alternative drugs. As such, the formulary exception requirements have not been met.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 Ciclopirox 0.77 percent gel 45 grams per 20 days to treat tinea pedis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the quantity prescribed was medically necessary for the enrollee. We received additional documentation and included it in the review. However, we did not receive the requested information to address the quantity exception.The plan limits the amount of Ciclopirox to plan 45 grams per 28 days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the diagnosis or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Estradiol Micronized powder 0.24 grams prescribed to treat postmenopausal hormone replacement. 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 plan denied your request for reimbursement because the drug does not meet the definition of a Part D drug. The National Drug Code verified with the Food and Drug Administration that the National Drug Code number is not valid. Therefore, the drug is not eligible for coverage under Medicare Part D. We determined the plan is not required to provide reimbursement for the Estradiol Micronized powder.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Progesterone Micronized 0.25 grams prescribed to treat postmenopausal hormone replacement. 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 plan denied your request for reimbursement because the drug does not meet the definition of a Part D drug. The National Drug Code verified with the Food and Drug Administration that the National Drug Code number is not valid. Therefore, the drug is not eligible for coverage under Medicare Part D. We determined the plan is not required to provide reimbursement for the Progesterone Micronized.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Testosterone 0.045 grams prescribed to treat postmenopausal hormone replacement. 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 plan denied your request for reimbursement because the drug does not meet the definition of a Part D drug. The National Drug Code verified with the Food and Drug Administration that the National Drug Code number is not valid. Therefore, the drug is not eligible for coverage under Medicare Part D. We determined the plan is not required to provide reimbursement for the Testosterone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Autologous Serum Ophthalmic 20 percent compound drop prescribed for the treatment of dry eye 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. This includes the case file from the plan, and any information submitted at the reconsideration level.Autologous Serum Ophthalmic drops have not been approved by the Food and Drug Administration (FDA) because the drops are a unique blood product and cannot be mass-produced for FDA approval. Drugs not approved by the FDA are excluded from Part D coverage. Therefore, the requested drops are excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a tiering exception request for Ertapenem 1 gram vial to treat septic arthritis and osteomyelitis of left hip, infection with extended-spectrum beta-lactamase producing Escherichia coli. 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.Ertapenem is a generic drug on Tier 4 of the plans formulary. The prescriber has stated that all lower tiered drugs to treat the diagnosis are contraindicated due to an enrollee allergy to the lower tier antibiotics to treat diagnosis. Therefore, Ertapenem is eligible for an exception. A physician reviewer determined that tiering exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ilevro 0.3 percent ophthalmic drops prescribed for cataract surgery. The Part D plan auto-forwarded the request.We received a 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 plan submitted documentation that shows the enrollee was in the initial coverage stage when the drug was purchased on dates of service January 11, 2023 and February 27, 2023. The claim information provided shows the tier 3 drug was approved, and a copay of $47.00 was charged to the enrollee at the point of sale for each of the dates of service requested. The plan's Evidence of Coverage indicates the copay amounts were charged correctly, based on standard cost sharing for a 30 day supply of a tier 3 drug purchased at a network pharmacy. Therefore, no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin 10 milligram extended release 12 hour tablet for unknown diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 plan submitted documentation that shows the claim for Oxycontin was approved and copayment was charged correctly to the enrollee at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Albuterol Sulfate Hydrofluoroalkane (HFA) 200 microgram inhaler prescribed for an unspecified 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 shows the enrollee requested the Part D plan to provide reimbursement for the requested drug purchased on December 8, 2021 from a network pharmacy, and processed through the enrollee's prior Part D plan, GEHA in error. The enrollee submitted GEHA's overpayment recovery letter, and explanation of benefits (EOB), which includes the copayment amounts paid by the enrollee and the amounts paid by GEHA. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Amlodipine Besylate 10 milligram tablet prescribed for an unspecified 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 shows the enrollee requested the Part D plan to provide reimbursement for the requested drug purchased on December 15, 2021 from a network pharmacy, and processed through the enrollee's prior Part D plan, GEHA in error. The enrollee submitted GEHA's overpayment recovery letter, and explanation of benefits (EOB), which includes the copayment amounts paid by the enrollee and the amounts paid by GEHA. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Amlodipine Besylate 10 milligram tablet prescribed for an unspecified 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 shows the enrollee requested the Part D plan to provide reimbursement for the requested drug purchased on March 5, 2022 from a network pharmacy, and processed through the enrollee's prior Part D plan, GEHA in error. The enrollee submitted GEHA's overpayment recovery letter, and explanation of benefits (EOB), which includes the copayment amounts paid by the enrollee and the amounts paid by GEHA. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Budesonide/Formoterol Fumarate Dihydrate 80/4.5 microgram inhalation prescribed for an unspecified 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 shows the enrollee requested the Part D plan to provide reimbursement for the requested drug purchased on December 10, 2021 from a network pharmacy, and processed through the enrollee's prior Part D plan, GEHA in error. The enrollee submitted GEHA's overpayment recovery letter, and explanation of benefits (EOB), which includes the copayment amounts paid by the enrollee and the amounts paid by GEHA. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Budesonide/Formoterol Fumarate Dihydrate 80/4.5 microgram inhalation prescribed for an unspecified 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 shows the enrollee requested the Part D plan to provide reimbursement for the requested drug purchased on January 6, 2022 from a network pharmacy, and processed through the enrollee's prior Part D plan, GEHA in error. The enrollee submitted GEHA's overpayment recovery letter, and explanation of benefits (EOB), which includes the copayment amounts paid by the enrollee and the amounts paid by GEHA. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Ciprofloxacin Hydrochloride 500 milligram tablet prescribed for an unspecified 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 shows the enrollee requested the Part D plan to provide reimbursement for the requested drug purchased on May 9, 2022 from a network pharmacy, and processed through the enrollee's prior Part D plan, GEHA in error. The enrollee submitted GEHA's overpayment recovery letter, and explanation of benefits (EOB), which includes the copayment amounts paid by the enrollee and the amounts paid by GEHA. Therefore, we determined the reimbursement criteria have been met.