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

At issue is Freestyle Libre 2 Sensor prescribed for type II diabetes with hyperglycemia. 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 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 determined the plan is not required to cover the Freestyle Libre 2 Sensor because it is not considered a medical supply directly associated with the injection of insulin. Although, this supply is not covered under Part D, it may be covered under Part B. This decision does not address the medical necessity or appropriateness of the supply. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synvisc 16 milligram/2 milliliter solution prefilled syringe prescribed for bilateral knee 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 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 determined that the plan is not required to cover the requested drug. Synvisc is a drug that is injected into the knee and is considered a device by the Food and Drug Administration.  Therefore, the device is excluded from coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Arikayce 590-milligram/8.4-milliliter nebulizer solution to treat mycobacterium abscessus infection. 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 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 NP Thyroid 60-milligram tablet to treat an unknown condition. 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 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.Drugs that are not approved by the Food and Drug Administration are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10-milligram tablet to treat major depressive disorder, recurrent and generalized anxiety 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 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 Clobetasol Propionate 0.05% Topical Cream to treat bullous disorder, unspecified.  The requested drug is not on the plans formulary. 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 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 asked your prescriber to send us a prescriber statement, a medically accepted indication (diagnosis), answers to non-formulary exception coverage criteria, and medical records. However, we did not receive the documentation.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 medical records do not support why other drugs on the plans formulary would not work for you.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 Mycophenolate Mofetil 360 milligram tablets to treat stage 3B chronic kidney disease, nephrotic syndrome with lesion of minimal change glomerulonephritis, and unspecified nephritic syndrome with minor glomerular abnormality. 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 Pantoprazole 40-milligram suspension. 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 a diagnosis and that all formulary alternatives were tried and failed or were contraindicated. However, we did not receive the requested information.At reconsideration, a diagnosis of gastroesophageal reflux disease was given. However, no documentation was provided by the prescriber to support this diagnosis. We requested information from the prescriber but no information was received. 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 Epclusa 400-milligram-100-milligram tablets to treat chronic viral hepatitis C. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300-milligram/2-milliter pen injector to treat atopic dermatitis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 3-percent gel 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 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 Rituxan 500-milligram/50-milliliter injection 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 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 Ipratropium-Albuterol 0.5-3 milligram/milliliter ampule prescribed for the treatment of chronic obstructive pulmonary disease. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the requested drug is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Oxycontin 60-milligram tablets to treat post laminectomy 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 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. Letter of September 28, 2021, signed by prescriber, effectively rules out all other formulary alternatives likely to be effective. 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: Favorable

At issue is Nuzyra 150-milligram tablets to treat mycobacterium abscessus infection. 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. We received additional documentation and included it in the review.The Medicare approved compendia support the drug at issue has an orphan drug designation for use in infections caused by nontuberculous mycobacterium. The drug at issue is not on the plans formulary. The prescriber provided patient specific clinical rationale supported by documentation to indicate the drug at issue is to be used in combination therapy with two formulary alternatives. The remaining drugs on the plans formulary were addressed as resistant to the strain of infection. 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 a tiering exception request for Entresto 97-milligram/103-milligram tablets to treat ischemic cardiomyopathy. 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.Entresto 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 Mycophenolate 500-milligram tablet to treat connective tissue disease associated with interstitial lung 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 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.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 condition. 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 Amitiza 24-microgram capsule to treat irritable bowel syndrome with constipation. 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 Zolpidem Tartrate 10-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.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 Premarin Vaginal Cream 0.625-milligram for an unstated condition. 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.Premarin 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/biologic 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 Nexletol 180-milligram tablets to treat hyperlipidemia. 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 Alprazolam 0.5 milligram tablet prescribed for unknown diagnosis. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration levelThe submitted documentation shows the requested drug was given to the enrollee while in an outpatient stay in the hospital. The provided documentation includes a copy of an itemized hospital bill and a canceled check as evidence that the drug was paid in full by the enrollee. Therefore, we determined reimbursement criteria has been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Amlodipine 5 milligram tablet prescribed for unknown diagnosis. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration levelThe submitted documentation shows the requested drug was given to the enrollee while in an outpatient stay in the hospital. The provided documentation includes a copy of an itemized hospital bill and a canceled check as evidence that the drug was paid in full by the enrollee. Therefore, we determined reimbursement criteria has been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Benzonatate 200 milligram prescribed for unknown diagnosis. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration levelThe submitted documentation shows the requested drug was given to the enrollee while in an outpatient stay in the hospital. The provided documentation includes a copy of an itemized hospital bill and a canceled check as evidence that the drug was paid in full by the enrollee. Therefore, we determined reimbursement criteria has been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Budesonide 0.5 milligram nebulizer prescribed for unknown diagnosis. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration levelThe submitted documentation shows the requested drug was given to the enrollee while in an outpatient stay in the hospital. The provided documentation includes a copy of an itemized hospital bill and a canceled check as evidence that the drug was paid in full by the enrollee. Therefore, we determined reimbursement criteria has been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Donepezil 5 milligram tablet prescribed for unknown diagnosis. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration levelThe submitted documentation shows the requested drug was given to the enrollee while in an outpatient stay in the hospital. The provided documentation includes a copy of an itemized hospital bill and a canceled check as evidence that the drug was paid in full by the enrollee. Therefore, we determined reimbursement criteria has been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Escitalopram 10 milligram tablet prescribed for unknown diagnosis. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration levelThe submitted documentation shows the requested drug was given to the enrollee while in an outpatient stay in the hospital. The provided documentation includes a copy of an itemized hospital bill and a canceled check as evidence that the drug was paid in full by the enrollee. Therefore, we determined reimbursement criteria has been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Guaifenesin/Codeine liquid prescribed for unknown diagnosis. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration levelThe submitted documentation shows the requested drug was given to the enrollee while in an outpatient stay in the hospital. The provided documentation includes a copy of an itemized hospital bill and a canceled check as evidence that the drug was paid in full by the enrollee. Therefore, we determined reimbursement criteria has been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Hydrocodone/APAP 10/325 milligram prescribed for unknown diagnosis. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration levelThe submitted documentation shows the requested drug was given to the enrollee while in an outpatient stay in the hospital. The provided documentation includes a copy of an itemized hospital bill and a canceled check as evidence that the drug was paid in full by the enrollee. Therefore, we determined reimbursement criteria has been met.