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

At issue is Vascepa 1-gram tablet to treat hypertriglyceridemia . 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 coverage for the non-formulary drug, Mupirocin Calcium 2% topical cream. 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 documentation submitted.The diagnosis provided by the prescriber for the requested drug is not legible. During this review, a request was submitted to the prescriber to clarify the condition being treated and to address the alternative drugs on the plans formulary to treat the enrollees condition. However, the prescriber did not respond to the request. Without a legible diagnosis, it is not possible to determine if the 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 Emgality 120-milligram/milliliter injection to treat chronic migraine without aura. 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: At-Risk Determination
Decision: Unfavorable

We received an auto-forwarded reconsideration request from the plan to review the enrollees at-risk determination. The plan imposed a 90 morphine milligram equivalent (MME) restriction per day.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the plan, on April 20, 2021, identified six separate prescribers of opioid medications in the enrollees history. The enrollee also was identified as using three unique pharmacies and had a six-month average daily morphine milligram equivalent (MME) use of 130 in the time from from August 21, 2020, through February 21, 2021. On March 10, 2021, prescriber outreach letters were sent to five opioid medication prescribers and one benzodiazepine prescriber, Initial written outreach resulted in three responses. On May 26, 2021, the plan limited access to the beneficiary to prescription opioid medications above a maximum 90 MME per day. On November 29, 2021, the enrollee appeared on the daily report due to denial of an opioid prescription. Outreach to provider determined the enrollee was under a strict pain contract. Provider stated preferred enrollee remains at an MME below 90 and continue to be tapered. Limit was set to expire on May 25, 2022. On April 19, 2022, the plan made the decision to extend limit for an additional 12 months. After limit extension, the enrollee appeared again on the report on May 16, 2022, for denial of an opioid with issuing prescriber Dr. Walter Boisvert. On May 16, 2022, the plan contacted the prescriber and was advised by office staff the prescription was not to be filled until May 16, 2022. The enrollees pain treatment is being managed by Dr. Boisvert. On April 22, 2022, the plan indicated the previously mentioned restriction will continue. A physician reviewed the appeal and determined the enrollee is considered at-risk.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5 milligram tablet. 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 documentation submitted. Eliquis 5 milligram tablet 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. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. 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 a tiering exception request for Nitroglycerin 0.4 milligram sublingual tablet. 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 documentation submitted. Nitroglycerin 0.4 milligram sublingual tablet is a generic drug on Tier 3 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 a direct member reimbursement request for Armodafanil 250-milligram tablet. The case was auto-forwarded by the plan.We received the submitted documentation to perform an independent and de novo review.The submitted documentation does not include 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 Fluconazole 150 milligram tablets. 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 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 direct member reimbursement request for Engerix-B vaccination. We received the submitted documentation to perform an independent and de novo review. The submitted documentation does not include a case file from the plan, medical records or evidence of a prescribed diagnosis. Therefore, we cannot determine 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 a direct member reimbursement for Vaqta 1 milliliter solution. We received the submitted documentation to perform an independent and de novo review. The submitted documentation does not include a case file from the plan, medical records or evidence of a prescribed diagnosis. Therefore, we cannot determine 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 coverage for Hetlioz 20 milligram capsule to treat non-24-hour sleep-wake disorder. 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 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 that must be met before coverage can be approved. The submitted documentation does not support that all of the plans requirements for coverage have 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 a reimbursement request for Allergy Relief 180 milligram tablets. 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 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 Humulin N 100 unit per milliliter solution. 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 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 Ozempic 4 milligram per 3 milliliter solution. 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 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 tiering exception request for Ondansetron 4-milligram ODT tablet to treat your condition. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Ondansetron 4-milligram ODT tablet 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 Hetlioz 20-milligram capsule to treat non-24 hour sleep wake disorder. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The 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 Rybelsus 7-milligram tablet 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.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 Restasis 0.05 percent ophthalmic dropperette to treat keratoconjunctivitis sicca. 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. Restasis 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 a tiering exception request for Nurtec 75 milligram oral disintegrating tablet to treat 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, 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 Dexilant DR 60-milligram capsule to treat gastro-esophageal reflux 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.Dexilant DR 60-milligram capsule 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 a tiering exception request for Fluphenazine 2.5 milligram tablet to treat schizoaffective disorder. The Part D plan auto-forwarded the request to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. During this review, we requested a prescriber statement and supporting medical records from the prescriber to support that all lower-tier drugs to treat the enrollees condition were tried and failed, or were contraindicated. The prescriber did not respond to the request.Fluphenazine is a generic drug on Tier 4 of the plans formulary. The prescriber has not addressed the drugs of the same type on the lower tiers of the plans formulary to treat the enrollees condition and provide patient specific clinical rationale as to why the lower-tiered brand drugs have been tried and failed, or are contraindicated.A physician reviewer determined that tiering exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trikafta 100 milligram-50 milligram-75 milligram and 150 milligram tablet therapy pack (86 tablets per 28 days) to treat cystic fibrosis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the quantity prescribed was medically necessary for the enrollee. We received additional documentation and included it in the review.The plan limits the amount of Trikafta to 84 tablets per 28 days. The prescriber indicates the amount allowed by the plan is sufficient. However, the claim at issue is for 86 tablets per 28 days, which is not medically necessary. The prescriber will have to resubmit the claim to the plan for an initial coverage determination of 84 tablets per 28 days. Therefore, an exception to the plans coverage criteria is not supported. 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 Nystatin 100,000 units per gram powder. The case was auto-forwarded by the plan.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 Freestyle Libre two sensor kit.  We received the submitted documentation to perform an independent and de novo review. The submitted documentation does not include a case file from the plan, medical records or evidence of a prescribed diagnosis. Therefore, we cannot determine 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 a tiering exception request for Abiraterone Acetate 250 milligram tablet to treat your condition. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Abiraterone Acetate 250 milligram tablet is a generic drug on Tier 4 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 Bystolic 5 milligram tablet to treat chronic systolic (congestive) heart failure and unspecified atrial fibrillation. 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. 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 Yuvafem 10-microgram tablet.  We received the submitted documentation to perform an independent and de novo review. The submitted documentation does not include a case file from the plan, medical records or evidence of a prescribed diagnosis. Therefore, we cannot determine 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 Sildenafil 20 milligram tablet. 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 a tiering exception request for Shingrix vial kit to treat shingles prophylaxis. 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. Shingrix vial kit is a brand biologic on Tier 3 of the plans formulary. There are no brand biologics 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 exceptionriteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Saxenda 6-milligram/milliliter solution to treat your condition. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Drugs prescribed for the treatment of weight loss are excluded from coverage. Therefore, this drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Freestyle Sensor Kit prescribed for 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.  Supplies for testing and monitoring blood glucose levels are not considered Part D drugs and may be covered under the Medicare Part B durable medical equipment benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Ventolin HFA 108 (90 base) microgram/actuation 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. Ventolin HFA 108 (90 base) microgram/actuation 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 drugis not eligible for a tiering exception. A physician reviewer determined that the tiering exception criteria are not met.