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

At issue is coverage for Relyvrio 3 gram/1 gram per packet oral powder for suspension to treat amyotrophic lateral sclerosis. 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 available documentation.The requested drug is not on the plans formulary. 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 prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, 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 coverage for Sandostatin LAR Depot 20 milligram vial to treat gastrointestinal bleeding due to polyps. 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 available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition 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 drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Oxycodone-Acetaminophen 10/325 milligram tablet, 100 tablets per 8 days, to treat neoplasm related 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 available documentation.Oxycodone-Acetaminophen 10/325 milligram tablet is a generic drug on Tier 3 of the plans formulary. The prescriber has not provided patient-specific clinical rationale as to why all of the lower-tiered alternative drugs on the plans formulary to treat the enrollees condition are contraindicated. Therefore, the tiering exception requirements have not been met.A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Amoxicillin 500 milligram capsule. 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 available documentation.The enrollee has requested the Part D plan to provide additional reimbursement for the requested drug purchased for all dates of fill that were processed through the enrollee's Part D plan, Navitus, in error. However, the plan indicates that there is missing information needed to consider the request. The required information should include an overpayment or recovery letter, which includes the copayment amounts by Navitus. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information. Please provide this information to the plan for reimbursement consideration.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Prednisolone Acetate 1 percent drops 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 available documentation.The enrollee has requested the Part D plan to provide additional reimbursement for the requested drug purchased for all dates of fill that were processed through the enrollee's Part D plan, Navitus, in error. However, the plan indicates that there is missing information needed to consider the request. The required information should include an overpayment or recovery letter, which includes the copayment amounts by Navitus. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information. Please provide this information to the plan for reimbursement consideration.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Propranolol Hydrochloride 10 milligram tablet. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The enrollee has requested the Part D plan to provide additional reimbursement for the requested drug purchased for all dates of fill that were processed through the enrollee's Part D plan, Navitus, in error. However, the plan indicates that there is missing information needed to consider the request. The required information should include an overpayment or recovery letter, which includes the copayment amounts by Navitus. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information. Please provide this information to the plan for reimbursement consideration.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Simvastatin 20 milligram tablet. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The enrollee has requested the Part D plan to provide additional reimbursement for the requested drug purchased for all dates of fill that were processed through the enrollee's Part D plan, Navitus, in error. However, the plan indicates that there is missing information needed to consider the request. The required information should include an overpayment or recovery letter, which includes the copayment amounts by Navitus. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information. Please provide this information to the plan for reimbursement consideration.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Spironolactone 100 milligram tablet. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The enrollee has requested the Part D plan to provide additional reimbursement for the requested drug purchased for all dates of fill that were processed through the enrollee's Part D plan, Navitus, in error. However, the plan indicates that there is missing information needed to consider the request. The required information should include an overpayment or recovery letter, which includes the copayment amounts by Navitus. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information. Please provide this information to the plan for reimbursement consideration.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Sulfamethoxazole/Trimethoprim 800/160 milligram tablet. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The enrollee has requested the Part D plan to provide additional reimbursement for the requested drug purchased for all dates of fill that were processed through the enrollee's Part D plan, Navitus, in error. However, the plan indicates that there is missing information needed to consider the request. The required information should include an overpayment or recovery letter, which includes the copayment amounts by Navitus. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information. Please provide this information to the plan for reimbursement consideration.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Triamcinolone Acetonide 0.1 percent ointment. 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 available documentation.The enrollee has requested the Part D plan to provide additional reimbursement for the requested drug purchased for all dates of fill that were processed through the enrollee's Part D plan, Navitus, in error. However, the plan indicates that there is missing information needed to consider the request. The required information should include an overpayment or recovery letter, which includes the copayment amounts by Navitus. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information. Please provide this information to the plan for reimbursement consideration.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Admelog Solostar 100 units per milliliter solution pen injector to treat enrollee's condition. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.During this review, 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 deemed contraindicated. However, the prescriber did not respond to our request.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The submitted documentation does not include medical records or evidence of a prescribed diagnosis. This information was requested by the Part D plan with no response from the prescriber/prescribers office. The documentation submitted at reconsideration also does not include medical records or evidence of a prescribed diagnosis. As such, there is insufficient documentation available to establish that the requested drug has been prescribed for a medically accepted indication. As this drug is not eligible for Part D coverage, it is not eligible for consideration for a formulary exception.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 Levothyroxine 25 microgram capsule to treat hypothyroidism. The Part D plan auto-forwarded the case to us for review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.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.The requested drug is not on the plans formulary. 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 prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not confirm that the enrollee has tried and failed the formulary alternative drugs. Therefore, 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 coverage for Farxiga 5 milligram tablet to treat type 2 diabetes mellitus. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that all lower-tiered drugs to treat the enrollees condition were tried and failed or were deemed contraindicated. However, the prescriber did not respond to our request.Farxiga is a brand drug on Tier 3 of the plans formulary. The prescriber has not provided patient-specific clinical rationale as to why all of the lower-tiered alternative drugs on the plans formulary to treat the enrollees condition are contraindicated. Therefore, the tiering exception requirements have not been met. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Lidocaine 5 percent patch to treat recurrent back pain. 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 available documentation. During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the diagnosis and treatment plan for recurrent back pain. However, the prescriber did not respond to our request.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition 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 drug is being prescribed for a non-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 coverage for Lidocaine 5 percent patch. The Part D plan auto-forwarded the case to us for review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.During this review, we requested additional information from the prescriber. Specifically, we requested a diagnosis and medical records to support that the requested medication is being used for a condition supported in one of Medicares compendia. However, the prescriber did not respond to our request.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The submitted documentation does not include medical records or evidence of a prescribed diagnosis. This information was requested by the Part D plan with no response from the prescriber/prescribers office. The documentation submitted at reconsideration also does not include medical records or evidence of a prescribed diagnosis. As such, there is insufficient documentation available to establish that the requested drug has been 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 coverage for Lidocaine 5 percent patch to treat chronic nerve pain/neuropathic pain due to an unspecified underlying condition. 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 available documentation.The Part D plan is responsible for determining whether the requested drug has been prescribed for a medically accepted indication outlined in the Medicare approved compendia. The provided diagnosis of chronic nerve pain/neuropathic pain, by itself, is not sufficient to determine if the requested drug has been prescribed for a medically accepted indication. During this review, we requested medical records and a prescriber statement to clarify the enrollees diagnosis and to address the plans coverage requirements for the drug. The prescriber did not respond to the request. As such, there is insufficient documentation available to establish that the requested drug has been 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: Favorable

At issue is TDAP vaccine prescribed for vaccination. 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 enrollee received the vaccine at the prescriber's office. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or prescribers office. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement from the prescribers office and a proof of payment indicating full payment was made for the vaccine and administration fee. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Morphine Sulfate ER 60 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. This includes the case file from the plan, and any information submitted at the reconsideration level.The plans 2023 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 claim information shows the cost of the drug was more than the plan approved amount. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Oxycodone Hydrochloride 15 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. This includes the case file from the plan, and any information submitted at the reconsideration level.The plans 2023 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 claim information shows the cost of the drug was more than the plan approved amount. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Zoster vaccine and administration fee prescribed for vaccination. 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 enrollee received the vaccine at the prescriber's office. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or prescribers office. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement from the prescribers office and a cancelled check indicating full payment was made for the vaccine and administration fee. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Hepatitis A vaccine and administration fee prescribed for vaccination. 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 enrollee received the vaccine at the prescriber's office. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or prescribers office. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement from the prescribers office and a proof of payment indicating full payment was made for the vaccine and administration fee. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Typhoid vaccine and administration fee prescribed for vaccination. 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 enrollee received the vaccine at the prescriber's office. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or prescribers office. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement from the prescribers office and a proof of payment indicating full payment was made for the vaccine and administration fee. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Yellow Fever vaccine and administration fee prescribed for vaccination. 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 enrollee received the vaccine at the prescriber's office. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or prescribers office. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement from the prescribers office and a proof of payment indicating full payment was made for the vaccine and administration fee. Therefore, we determined the reimbursement criteria have been met.