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

At issue is Diphtheria-Tetanus toxoids-ped 5-25/0.5 milliliter vaccine prescribed for vaccination. The Part D plan denied the request.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 level.The enrollee is requesting reimbursement for the vaccine obtained and administered in the physicians office. The submitted documentation does not include an approved National Drug Code (NDC) by the Food and Drug Administration (FDA) for the requested vaccine. Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gammaplex Injection 10-percent to treat myopathy, unspecified. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The 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 Apo-Varenicl 0.5 milligram tablet prescribed for diagnosis not provided. 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 plan provided documentation showing the requested drug was purchased by the enrollee for an amount that is less than or equal to the required low-income subsidy (LIS) copayment. 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 Apo-Varenicl 1 milligram tablet prescribed for diagnosis not provided. 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 plan provided documentation showing the requested drug was purchased by the enrollee for an amount that is less than or equal to the required low-income subsidy (LIS) copayment. 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 Cephalexin 500 milligram capsule prescribed for diagnosis not provided. 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 plan submitted documentation showing the enrollee was reimbursed for the plans share of the cost for the requested drug for dates of fill ranging from February 4, 2019 through May 17, 2021. The reimbursement amount was based on the plans approved amount for the requested drug, minus the enrollees low income subsidy copay. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Citalopram 40 milligram tablet prescribed for diagnosis not provided. 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 plan submitted documentation showing the enrollee was reimbursed for the plans share of the cost for the requested drug for dates of fill ranging from February 4, 2019 through May 17, 2021. The reimbursement amount was based on the plans approved amount for the requested drug, minus the enrollees low income subsidy copay. Therefore, we determined that the plan is not required to provide further reimbursement. The enrollee also requested reimbursement for dates of fill for the year 2018. However, the request exceeds the three year limit for timely filing of reimbursement requests.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clindamycin 1 percent pad prescribed for diagnosis not provided. 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 plan submitted documentation showing the enrollee was reimbursed for the plans share of the cost for the requested drug for dates of fill ranging from February 4, 2019 through May 17, 2021. The reimbursement amount was based on the plans approved amount for the requested drug, minus the enrollees low income subsidy copay. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ferosul 325 milligram tablet prescribed for diagnosis not provided. 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 Metronidazole 500 milligram tablet prescribed for diagnosis not provided. 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 plan provided documentation showing the requested drug was purchased by the enrollee for an amount that is less than or equal to the required low-income subsidy (LIS) copayment. 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 Olanzapine 10 milligram tablet prescribed for diagnosis not provided. 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 plan provided documentation showing the requested drug was purchased by the enrollee for an amount that is less than or equal to the required low-income subsidy (LIS) copayment. 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 Olanzapine 20 milligram tablet prescribed for diagnosis not provided. 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 plan submitted documentation showing the enrollee was reimbursed for the plans share of the cost for the requested drug for dates of fill ranging from February 4, 2019 through May 17, 2021. The reimbursement amount was based on the plans approved amount for the requested drug, minus the enrollees low income subsidy copay. The dates of fill September 21, 2020 and October 22, 2020 were purchased by the enrollee for an amount that is less than or equal to the required low-income subsidy (LIS) copayment Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pantoprazole Sodium delayed release 40 milligram tablet prescribed for diagnosis not provided. 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 plan provided documentation showing the requested drug was purchased by the enrollee for an amount that is less than or equal to the required low-income subsidy (LIS) copayment. 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 Prednisone 10 milligram tablet prescribed for diagnosis not provided. 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 plan submitted documentation showing the enrollee was reimbursed for the plans share of the cost for the requested drug for dates of fill ranging from February 4, 2019 through May 17, 2021. The reimbursement amount was based on the plans approved amount for the requested drug, minus the enrollees low income subsidy copay. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Preplus 27-1 milligram 40 milligram tablet prescribed for diagnosis not provided. 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 plan submitted documentation showing the enrollee was reimbursed for the plans share of the cost for the requested drug for dates of fill ranging from February 4, 2019 through May 17, 2021. The reimbursement amount was based on the plans approved amount for the requested drug, minus the enrollees low income subsidy copay. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trazodone 150 milligram tablet prescribed for diagnosis not provided. 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 plan submitted documentation showing the enrollee was reimbursed for the plans share of the cost for the requested drug for dates of fill ranging from February 4, 2019 through May 17, 2021. The reimbursement amount was based on the plans approved amount for the requested drug, minus the enrollees low income subsidy copay. Therefore, we determined that the plan is not required to provide further reimbursement. The enrollee also requested reimbursement for dates of fill for the year 2018. However, the request exceeds the three year limit for timely filing of reimbursement requests.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Losartan 25-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. The requested drug is a generic drug on Tier 2 of the plans formulary.  The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug. 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 Otezla 30-milligram tablet to treat plaque psoriasis. 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 Levothyroxine 75 milligram tablet prescribed for diagnosis not provided. 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. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan submitted documentation that indicates the enrollee was in the deductible stage of the Part D benefit when the requested drug was purchased. The plans 2022 Evidence of Coverage states that the enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. Therefore, we determined the plan is not required to provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Symproic 0.2-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 documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are 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 a tiering exception request for Ozempic 0.25 or 0.50 pen injector to treat type 2 diabetes mellitus. 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.Ozempic 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 Oxycontin 40-milligram extended-release 12-hour abuse-deterrent tablets 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 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 Edarbi 80-milligram tablet to treat hypertension. 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, in the form of medical records (or lack of records), 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 Topiramate, Celecoxib, Gabapentin, Lidocaine, Versapro cream base, Propylene Glycol, Ethoxydiglyco, and Ethyl Alcohol compounded drug to treat idiopathic peripheral neuropathy. 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 Qualified Independent Contractor notes this drug is a compounded drug. Therefore, we reviewed each ingredient individually.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, Versapro, Propylene Glycol, Ethoxydiglycol and Ethyl alcohol are excluded from coverage.The use of Topiramate, Celocoxib, Gabapentin, and Lidocaine 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 Nubeqa 300-milligram tablet to treat metastatic castrate sensitive prostate cancer. 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 Teriparatide 620-microgram per 2.48-milliliter injection to treat postmenopausal osteoporosis. 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 Entresto 24-milligram to 26-milligram tablets to treat chronic combined systolic and diastolic congestive heart failure. 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 Cyclobenzaprine Hydrochloride 10-milligram tablet to treat other dystonia (G24.8) and idiopathic nonfamilial dystonia (G24.2). 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 a tiering exception request for Rocklatan 0.02-0.005 percent eye drops to treat primary open-angle glaucoma, right eye. 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 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.