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

At issue is coverage for Adbry 150 milligram per milliliter syringe to treat atopic dermatitis. 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 drug on the plans formulary to treat the enrollees condition (Dupixent subcutaneous syringe) 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 the formulary alternative drug. 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: Favorable

At issue is coverage for Dextroamphetamine-Amphetamine 10 milligram tablet to treat attention deficit disorder without hyperactivity. 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 diagnosis initially provided to the plan for the requested drug was behavioral and emotional disorders with onset usually occurring in childhood and adolescence, generalized anxiety disorder and tic disorder unspecified. However, 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. At reconsideration, a new diagnosis of attention deficit disorder has been noted. This diagnosis was not initially provided to the plan. Medical records have been submitted to validate this additional diagnosis. 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 a medically accepted indication for the drug as outlined in the Medicare approved compendium, Drugdex. Therefore, the drug is being prescribed for a medically accepted indication. 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 coverage for Dorzolamide/Timolol 2/0.5 percent ophthalmic solution prescribed to control eye pressure. 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 all of 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, no medical records have been submitted to confirm 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: Favorable

At issue is coverage for Vumerity DR (delayed release) 231 milligram capsule to treat multiple sclerosis, relapsing form. 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. The prescriber has 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. Specifically, the medical record dated May 24, 2023, confirms the patient has tried and failed 2 formulary alternative drugs, Copaxone and Betaseron, as required by the plan. Therefore, a formulary exception is supported in this case.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 coverage for Fluticasone/Salmeterol 250/50 microgram per actuation inhaler to treat asthma. 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 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

You requested reimbursement for a compound drug using Methylparaben 0.351 gram to treat your radiation proctitis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The National Drug Code (NDC) number (62991-1311-01) verified with the Food and Drug Administration that the NDC number is not valid. Therefore, the drug is not eligible for coverage under Medicare Part D. We determined the plan is not required to provide reimbursement for the compound drug.This decision does not address the medical necessity of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for a compound drug using Propylene Glycol 35 milliliters to treat your radiation proctitis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The National Drug Code (NDC) number (00574-0072-16) verified with the Food and Drug Administration that the NDC number is not valid. Therefore, the drug is not eligible for coverage under Medicare Part D. We determined the plan is not required to provide reimbursement for the compound drug.Furthermore, Propylene Glycol is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for a compound drug using Propylparaben 0.178 gram to treat your radiation proctitis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The National Drug Code (NDC) number (38779-1551-05) verified with the Food and Drug Administration that the NDC number is not valid. Therefore, the drug is not eligible for coverage under Medicare Part D. We determined the plan is not required to provide reimbursement for the compound drug.This decision does not address the medical necessity of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for compound drug Sucralfate 40 milligrams per milliliter enema suspension to treat radiation proctitis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Sucralfate has not been found by the Food and Drug Administration (FDA) to be safe and effective and the drug product labeling has not been approved by the FDA for enema administration. Drugs that are not FDA-approved do not meet the definition of a Part D drug and are excluded from Part D coverage. Therefore, the requested drug is excluded from Medicare Part D coverage.Furthermore, the National Drug Code (NDC) number (38779-0318-08) verified with the Food and Drug Administration that the NDC number is not valid. Therefore, the drug is not eligible for coverage under Medicare Part D. We determined the plan is not required to provide reimbursement for the compound drug.This decision does not address the medical necessity of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for a compound drug using Xanthan Gum 1.750 grams to treat your radiation proctitis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The National Drug Code (NDC) number (38779-1700-05) verified with the Food and Drug Administration that the NDC number is not valid. Therefore, the drug is not eligible for coverage under Medicare Part D. We determined the plan is not required to provide reimbursement for the compound drug.This decision does not address the medical necessity of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is poliovirus vaccine. 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 the enrollee requested the plan to provide reimbursement for a medication purchased from a network pharmacy. The plan's Evidence of Coverage states, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the documentation does not include the prescribing physicians name, address, and National Provider Identifier (NPI) number. Therefore, we determined that the plan is not required to reimburse the enrollee without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Tetanus/Diphtheria vaccination and administration fee. The Part D plan denied the request.We received a 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's Evidence of Coverage states, 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 submitted documentation does not include a valid proof of purchase for the drug at issue. Therefore, the request for reimbursement cannot be granted.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for HZV Recombinant and administration fee. The Part D plan denied the request.We received a 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's Evidence of Coverage states, 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 submitted documentation does not include a valid proof of purchase for the drug at issue. Therefore, the request for reimbursement cannot be granted.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Nurtec 75 milligram disintegrating tablet, 8 tablets per 8 days to treat migraine. 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 plans quantity limit for the requested drug is 16 tablets per 30 days. The prescriber has not provided patient-specific clinical rationale as to why the amount allowed by the plan would be ineffective in treating the diagnosis and/or would be contraindicated. Furthermore, the submitted documentation does not support the medical necessity for an exception to the plans quantity limit for the drug. A physician reviewed the appeal and determined that the requested drug at the requested amount is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Colchicine 0.6 milligram tablets prescribed for unknown diagnosis. 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 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 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 Jardiance 25 milligram tablets prescribed for unknown diagnosis. 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 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 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 coverage for Fentanyl 100 microgram patch to treat unknown diagnosis. 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 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. As such, there is insufficient documentation available to establish that the requested drug has been prescribed for a medically accepted indication. A quantity limit cannot be allowed for a drug that has not been approved for 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 coverage for Fentanyl 25 microgram patch to treat unknown diagnosis. 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 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. As such, there is insufficient documentation available to establish that the requested drug has been prescribed for a medically accepted indication. A quantity limit cannot be allowed for a drug that has not been approved for coverage.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 coverage for Rinvoq 45 milligram tablet to treat Crohn's disease. 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 Medicare approved compendium, DrugDex, includes an citation for the use of the requested drug to treat Crohn's disease. Therefore, the requested drug is being prescribed to treat a medically accepted indication.The plan has prior authorization requirements that must be met before coverage of this drug is provided. However, the plans prior authorization requirements are diagnosis-specific and not related to the condition being treated. Since the condition being treated is a medically accepted indication outlined in DrugDex, an exception to the plans diagnosis-specific coverage requirements is supported. 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 coverage for Creon 36000 unit/114000 unit capsule to treat exocrine pancreatic insufficiency. 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.Creon is a biologic drug on Tier 3 of the plans formulary. There are no biologic drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. 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 Privigen 10 percent injection solution to treat autoimmune encephalitis. 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 coverage for Clenpiq solution for colonoscopy bowel preparation. 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 Eliquis 5 milligram tablet to treat unknown diagnosis. 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.Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. 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 Zarxio 480 microgram per 0.8 milliliter injection solution to treat neutropenia associated with myelodysplastic syndrome. 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 plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.