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

At issue is coverage for Testosterone 1.62-percent topical gel prescribed for primary hypogonadism. 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 Part D plan has prior authorization requirements that have to be met before coverage of this drug is approved. The submitted documentation does not include any medical records to validate that the plans coverage criteria have been met. During this review, a request was submitted to the prescriber to address the plans coverage requirements and to provide supporting medical records. The prescriber did not respond to the request. As such, the prior authorization criteria have not 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 Otezla 30-milligram tablet 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 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 Imatinib Mesylate  400-milligram tablets to treat Philadelphia chromosome positive chronic myelogenous 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.The documentation satisfies the plans coverage criteria. Evidence of myeloid transformation on bone marrow and detection of BCR-ABL that is new is all indicative of diagnosis of chronic myelogenous leukemia, for which the medication in question is indicated.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 Cytomel 5-microgram tablet to treat hypothyroidism. 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: Favorable

At issue is Firdapse 10-milligram tablet to treat Lambert-Eaton myasthenic 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 documentation satisfies the plans coverage criteria. The plan's redetermination denial letter December 13, 2021 states that the appeal was denied because the enrollee did not try, fail or have a contraindication to the formulary drug Ruzurgi.  Please note that the Medicare approved compendia DrugDex states that the drug Ruzurgi is only for pediatric patients age 6-17 years of age.  The enrollee's date of birth is 11/2/1945.  The drug Firdapse is only for adults.  This appeal is for continuation of therapy which was previously approved by the plan in a letter dated 2/1/2021.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 Envarsus 1 milligram extended release tablet prescribed daily for kidney transplant. 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 also researched Medicare systems and reviewed the enrollment data available. We determined that the plan is not required to cover the drug. Medicare records indicate the enrollee received a kidney transplant, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and the requested drug is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. 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 Butalbital/Acetaminiophen/Caffeine/Codeine 50-milligram/325-milligram/40-milligram/30-milligram tablets to treat migraine headaches. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed or were contraindicated. However, we did not receive the requested information.The 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 Kisqali 500-milligram tablet to treat metastatic breast cancer, estrogen receptor positive, human epidural growth factor receptor 2 negative. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee has satisfied the plans prior authorization coverage criteria. We received additional documentation and included it in the review.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 a tiering exception request for Jakafi 10-milligram tablet to treat graft versus host disease. 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.This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules. A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Linzess 290-microgram capsule to treat constipation, unspecified. 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 Dexilant delayed release 60-milligram capsule 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.Dexilant 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 Accu Chek Softclix Lancet prescribed for an unknown diagnosis. 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 claims for the requested drug and adjusted the amount owed due to a change in the enrollee's Part D enrollment. We reviewed Medicare records, the plans formulary and Evidence of Coverage. In this case, the enrollee was not a member of the plan effective January 1, 2021. Therefore, the enrollee is responsible for the plan's cost share that was paid to the pharmacy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Accu Chek Aviva Plus prescribed for an unknown diagnosis. 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 claims for the requested drug and adjusted the amount owed due to a change in the enrollee's Part D enrollment. We reviewed Medicare records, the plans formulary and Evidence of Coverage. In this case, the enrollee was not a member of the plan effective January 1, 2021. Therefore, the enrollee is responsible for the plan's cost share that was paid to the pharmacy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is BD Pen Needle Short Ultra Fine 31 gauge X 8 millimeter prescribed for an unknown diagnosis. 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 claims for the requested drug and adjusted the amount owed due to a change in the enrollee's Part D enrollment. We reviewed Medicare record's, the plans formulary and Evidence of Coverage. In this case, the enrollee was not a member of the plan effective January 1, 2021. Therefore, the enrollee is responsible for the plan's cost share that was paid to the pharmacy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Chantix Starting Month Pak prescribed for an unknown diagnosis. 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 claims for the requested drug and adjusted the amount owed due to a change in the enrollee's Part D enrollment. We reviewed Medicare record's, the plans formulary and Evidence of Coverage. In this case, the enrollee was not a member of the plan effective January 1, 2021. Therefore, the enrollee is responsible for the plan's cost share that was paid to the pharmacy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Droplet Pen Needles 31 gauge X 8 millimeter prescribed for an unknown diagnosis. 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 claims for the requested drug and adjusted the amount owed due to a change in the enrollee's Part D enrollment. We reviewed Medicare record's, the plans formulary and Evidence of Coverage. In this case, the enrollee was not a member of the plan effective January 1, 2021. Therefore, the enrollee is responsible for the plan's cost share that was paid to the pharmacy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxyzine Pamoate prescribed for an unknown diagnosis. 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 claims for the requested drug and adjusted the amount owed due to a change in the enrollee's Part D enrollment. We reviewed Medicare record's, the plans formulary and Evidence of Coverage. In this case, the enrollee was not a member of the plan effective January 1, 2021. Therefore, the enrollee is responsible for the plan's cost share that was paid to the pharmacy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levemir Flextouch prescribed for an unknown diagnosis. 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 claims for the requested drug and adjusted the amount owed due to a change in the enrollee's Part D enrollment. We reviewed Medicare record's, the plans formulary and Evidence of Coverage. In this case, the enrollee was not a member of the plan effective January 1, 2021. Therefore, the enrollee is responsible for the plan's cost share that was paid to the pharmacy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic prescribed for an unknown diagnosis. 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 claims for the requested drug and adjusted the amount owed due to a change in the enrollee's Part D enrollment. We reviewed Medicare record's, the plans formulary and Evidence of Coverage. In this case, the enrollee was not a member of the plan effective January 1, 2021. Therefore, the enrollee is responsible for the plan's cost share that was paid to the pharmacy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Quetiapine Fumarate prescribed for an unknown diagnosis. 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 claims for the requested drug and adjusted the amount owed due to a change in the enrollee's Part D enrollment. We reviewed Medicare record's, the plans formulary and Evidence of Coverage. In this case, the enrollee was not a member of the plan effective January 1, 2021. Therefore, the enrollee is responsible for the plan's cost share that was paid to the pharmacy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Simvastatin prescribed for an unknown diagnosis. 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 claims for the requested drug and adjusted the amount owed due to a change in the enrollee's Part D enrollment. We reviewed Medicare record's, the plans formulary and Evidence of Coverage. In this case, the enrollee was not a member of the plan effective January 1, 2021. Therefore, the enrollee is responsible for the plan's cost share that was paid to the pharmacy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alprazolam 0.25-milligram oral disintegrating tablets to treat Menieres disease with severe vertigo. 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 Calcipotriene 0.005-percent foam to treat seborrheic dermatitis. 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 Tadalafil 20-milligram tablet to treat pulmonary hypertension, unspecified and pulmonary hypertension due to cryoglobulinemic vasculitis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Iprat-Albut 0.5-3-milligrams/3-milliliter nebulizer solution. 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. Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules. The drug is administered via nebulizer.According to Medicare rules, Medicare Part B payment may be made for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. 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 Stelara 45-milligrams/0.5-milliliter to treat Crohns 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 Cosopt PF 10 milliliter vial prescribed 180 milliliter for 90 days to treat open-angle glaucoma, both eyes. 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 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.The plan limits the amount of Cosopt PF to 10 milliliters per 30 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.