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

At issue is Raberprazole 20 milligram prescribed for an unspecified diagnosis. The Part D plan denied the 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 submitted documentation shows that the requested drug was purchased by the enrollee for an amount that is less than or equal to the required low-income subsidy (LIS) 15 percent copayment for date of service February 9, 2022. Therefore, we determined the requested drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rizatriptan 10 milligram prescribed for 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 plan submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the requested drug was purchased on January 4, 2022, and in the initial coverage stage for date of service January 23, 2022. The plans Evidence of Coverage states that the enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied, and in the initial coverage stage for low-income-subsidy eligible members, the amount of copay is less than or equal to 15 percent of the drug cost. Therefore, we determined the claims were paid appropriately and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rizatriptan 10 milligram prescribed for 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 plans 2022 Evidence of Coverage states, reimbursement for drugs is based the total cost of covered drugs, minus the required deductible, copay, or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The submitted documentation shows the claim was adjusted and the enrollee was reimbursed for the cost of the drug, minus the low-income subsidy 15 percent copay. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Valacyclovir 1 gram prescribed for an unspecified diagnosis. The Part D plan denied the 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 submitted documentation shows that the requested drug was purchased by the enrollee for an amount that is less than or equal to the required low-income subsidy (LIS) 15 percent copayment for date of service August 8, 2022. Therefore, we determined the requested drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyvanse 10 milligram prescribed for an unspecified diagnosis. The Part D plan denied the 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 submitted documentation shows that the requested drug was purchased by the enrollee for an amount that is less than or equal to the required low-income subsidy (LIS) 15 percent copayment for date of service January 27, 2022, February 24, 2022, and August 8, 2022. Therefore, we determined the requested drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyvanse 40 milligram prescribed for an unspecified diagnosis. The Part D plan denied the 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 submitted documentation shows that the requested drug was purchased by the enrollee for an amount that is less than or equal to the required low-income subsidy (LIS) 15 percent copayment for dates of service January 27, 2022, February 24, 2022, March 23, 2022, May 9, 2022, July 8, 2022, and August 8, 2022. Therefore, we determined the requested drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aluminum/Magnesium/Simethicone 200/200/20 milligram per 30 milliliter oral 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.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a direct member reimbursement for Hydrocodone/Acetaminophen 10 milligram/325 milligram tablets. 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. 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 Amlodipine Besylate 5 milligram tablet prescribed for an unspecified 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 the requested drug was approved and copayment was charged 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 deductible, copay, or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. We determined the copay was calculated correctly for a 90 day supply of this tier 1 drug purchased at a standard pharmacy, which was less than the required copayment of $42.00. Therefore, no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Losartan Potassium 100 milligram tablet prescribed for an unspecified 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 the requested drug was approved and copayment was charged 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 deductible, copay, or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. We determined the copay of $42.00 was calculated correctly for a 90 day supply of this tier 1 drug purchased at a standard pharmacy. Therefore, no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia injection prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Drugs furnished Incident To a physicians service are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 25 milligram tablet prescribed for an unspecified diagnosis. 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 plans 2022 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. The plan submitted documentation that shows the enrollee was in the initial coverage stage when the drug was purchased. The claim for a 100 day supply of the tier 3 drug was approved and a copay of $45.00 was charged to the enrollee at the point of sale. We determined the copay was calculated correctly, based on cost sharing for a 61-100 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 Ketorolac Tromethamine 0.5 percent drop prescribed for an unspecified diagnosis. The Part D plan auto-forwarded 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 a discount card was applied to the purchase of the requested drug. Discount cards are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When the enrollees benefit card was used, the enrollee acknowledged and agreed that the GoodRX discount program will be treated as the primary payor with respect to the medications that are purchased through the discount program. Therefore, the plan is not required to cover or provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Wegovy 0.25 milligram per 0.5 milliliter pen to treat obesity. 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.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.Drugs prescribed to treat weight gain (promote weight loss) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.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 Sildenafil 100 milligram tablets. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other diagnoses for which the drug is not Food and Drug Administration (FDA) approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dulera 100/5 microgram inhaler to treat chronic obstructive pulmonary disease. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level. The requested drug is not on the plans formulary. In order to grant an exception for a drug, not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why 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 Novolog 100 unit/milliliter (ml) vial 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.Novolog is a biologic on Tier 3 of the plans formulary. There are no biologic of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this 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 Wegovy 0.25 milligram per milliliter auto injector solution to treat enrollee's condition. The Part D plan auto forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed to treat weight gain (promote weight loss) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rivastigmine 4.6 milligram per 24 hour patch. 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 vascular and Alzheimer's type dementia. Originally a diagnosis of cognitive deficit due to and following cerebral vascular disease was supported by medical records prior to appeal. However, no documentation was provided by the prescriber to support Alzheimer's-type dementia on appeal. We are not able to determine whether the requested Rivastigmine patch was prescribed for a medically accepted indication. Therefore, the drug is not eligible for coverage under Medicare Part D. Of note, issue of formulary exception is not addressed at this time as drug has not been approved.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 Ilevro 0.3 percent ophthalmic suspension to treat diabetic retinopathy and macular degeneration. 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. 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 Insulin Lispro 100 unit per milliliter pen-injector to treat type 2 diabetes mellitus 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 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 a tiering exception request for Lamotrigine Extended Release 25 milligram tablet to treat schizoaffective disorder bipolar 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.Lamotrigine Extended Release is a brand on Tier 4 of the plans formulary. The prescriber has stated that all lower tiered drugs to treat the diagnosis have been tried and failed and provided reasons why they would likely not be as effective as the requested drug. Therefore, this drug is eligible for an exception.A physician reviewer determined that tiering exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sodium Citrate/Citric Acid 334/500 milligram per 5 milliliter solution for prevention of kidney stones. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs that are not approved by the Food and Drug Administration (FDA) are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha SureClick 140 milligram per milliliter solution auto injector. 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. Additionally, if a medically accepted indication was provided, 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 Rocklatan 0.02/0.005 percent solution to treat the chronic open angle glaucoma. 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.Rocklatan 0.02/0.005 percent solution is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cholestyramine 4 gram powder to treat lymphocytic colitis. 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 Lidocaine 5 percent patch to treat polyneuropathy, inflammatory polyarthropathy. 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 Relistor 12 milligram per 0.6 milliliter injection to treat opioid induced 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 documentation satisfies the plans coverage criteria. Prescriber provided information that patient has tried and failed Movantik. Prescriber currently is using a combination medication regiment of Lactulose, Miralax, Relistor, Amitiza, and Dulcolax suppositories to treat opioid induced constipation.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.