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

At issue is Levothyroxine 125 microgram prescribed for unknown diagnosis. 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 levelThe submitted documentation shows the requested drug was given to the enrollee while in an outpatient stay in the hospital. The provided documentation includes a copy of an itemized hospital bill and a canceled check as evidence that the drug was paid in full by the enrollee. Therefore, we determined reimbursement criteria has been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Losartan 100 milligram tablet prescribed for unknown diagnosis. 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 levelThe submitted documentation shows the requested drug was given to the enrollee while in an outpatient stay in the hospital. The provided documentation includes a copy of an itemized hospital bill and a canceled check as evidence that the drug was paid in full by the enrollee. Therefore, we determined reimbursement criteria has been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Methenamine Hippurate 1 milligram prescribed for unknown diagnosis. 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 levelThe submitted documentation shows the requested drug was given to the enrollee while in an outpatient stay in the hospital. The provided documentation includes a copy of an itemized hospital bill and a canceled check as evidence that the drug was paid in full by the enrollee. Therefore, we determined reimbursement criteria has been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Montelukast 10 milligram prescribed for unknown diagnosis. 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 levelThe submitted documentation shows the requested drug was given to the enrollee while in an outpatient stay in the hospital. The provided documentation includes a copy of an itemized hospital bill and a canceled check as evidence that the drug was paid in full by the enrollee. Therefore, we determined reimbursement criteria has been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Nifedlpine CR 30 milligram prescribed for unknown diagnosis. 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 levelThe submitted documentation shows the requested drug was given to the enrollee while in an outpatient stay in the hospital. The provided documentation includes a copy of an itemized hospital bill and a canceled check as evidence that the drug was paid in full by the enrollee. Therefore, we determined reimbursement criteria has been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Sucralfate 1 gram prescribed for unknown diagnosis. 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 levelThe submitted documentation shows the requested drug was given to the enrollee while in an outpatient stay in the hospital. The provided documentation includes a copy of an itemized hospital bill and a canceled check as evidence that the drug was paid in full by the enrollee. Therefore, we determined reimbursement criteria has been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Trazodone 100 milligram tablet prescribed for unknown diagnosis. 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 levelThe submitted documentation shows the requested drug was given to the enrollee while in an outpatient stay in the hospital. The provided documentation includes a copy of an itemized hospital bill and a canceled check as evidence that the drug was paid in full by the enrollee. Therefore, we determined reimbursement criteria has been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Vancomycin 125 milligram capsule prescribed for unknown diagnosis. 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 levelThe submitted documentation shows the requested drug was given to the enrollee while in an outpatient stay in the hospital. The provided documentation includes a copy of an itemized hospital bill and a canceled check as evidence that the drug was paid in full by the enrollee. Therefore, we determined reimbursement criteria has been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aspirin EC 81 milligram. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lactobacillus Acidophilus. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mirabegron 5 milligram to treat unknown 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.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 alternative drugs provided on the plans formulary list would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tadalafil 5-milligram tablets to treat benign prostatic hyperplasia. 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 the enrollee has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information.The documentation satisfies the plans coverage criteria. The submitted documentation supports the prescriber ordered the drug at issue for the enrollee's noted diagnosis. The prescriber submitted a statement to indicate the enrollee is not concurrently taking nitrates, and that the enrollee has had a trial and failure of an alpha-blocker (Terazosin). The plan's prior authorization coverage criteria has been met.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 Nurtec 75-milligram tablets to treat migraine headaches 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.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. However, we did not receive the requested information.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 alternative drugs provided on the plans formulary list 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 prior authorization for Humira CF pen 80-40 milligram to treat granuloma annulare. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Prolia 60-milligrams per milliliter to treat post-menopausal 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 documentation satisfies the plans coverage criteria. The enrollee previously received Zoledronic Acid infusions and Raloxifene for post-menopausal osteoporosis. The physicians notes document that the enrollee is no longer taking these drugs. The prior authorization criteria for the requested drug have been met.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 Qsymia ER 7.5/46-milligram tablet to treat weight loss/obesity. 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 to treat weight gain (promote weight loss) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prednisolone Acetate micronized/Gatifloxacin/Bromfenac Sodium Sesquihydrate 1/0.5/0.07 percent suspension prescribed for unknown diagnosis. 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.We determined the plan is not required to cover the requested compounded drug. According to Medicare rules, drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The requested drug is consistent of bulk powder ingredients and therefore, is excluded from coverage. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron 4-milligram tablets to treat nausea and vomiting. 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 Ketoconazole 200-milligram tablet. At initial determination and redetermination the diagnoses of superficial mycosis, unspecified, cellulitis, unspecified, and tinea pedis were given. 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 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.At reconsideration the diagnoses of superficial mycosis, unspecified, dermatophytosis, unspecified, tinea cruris, and candidiasis of skin, unspecified were given. No medical records were provided by the prescriber to support these diagnoses. It could not be determined whether the requested drug was being prescribed for medically accepted indications. Therefore, the requested drug 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 Mesalamine DR 1.2-gram tablet to treat ulcerative colitis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Mesalamine 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 Dupixent 300-milligram syringe to treat atopic dermatitis. 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 Proair Respiclick 90-micrograms/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.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee has satisfied the plans step therapy requirements. However, we did not receive the requested information.The prescriber has not indicated that all alternatives required by the plan have been tried and failed or why the plans required step therapy drugs would likely not be as effective as the requested drug. A physician reviewer determined that neither step therapy nor step therapy exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Livalo 1 milligram tablets to treat an unspecified diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.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 Xiidra 5 percent eye drops to treat sicca syndrome with keratoconjunctivitis. 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 alternative drugs provided on the plans formulary list 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 Trulicity 0.75-milligram/0.5-milliliter pen injector to treat type II 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 biologic is not on the plans formulary. In order to grant an exception for a biologic 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 alternative drugs provided on the plans formulary list 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 biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a direct member reimbursement request for Shingrix vaccination. 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. The record shows the enrollee received the vaccination at a physicians office. The plan submitted documentation that shows coverage was provided for the Shingrix vaccination. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the enrollees required copayment amount, and minus the difference between what the plan normally pays for the drug and what the provider charged the enrollee. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the copay. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Crestor 40-milligram tablets to treat coronary artery disease and mixed hyperlipidemia. 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 alternative drugs provided on the plans formulary list 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 Mefanamic Acid to treat dysmenorrhea. 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 Paxil 10-milligrams per 5-milliliter suspension prescribed for major depressive disorder. The Part D plan denied the request for a tiering exception.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. Paxil 10 milligrams per 5 milliliter suspension is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prempro 0.3-milligram/1.5-milligram tablets to treat menopausal and female climacteric states. 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 alternative drugs provided on the plans formulary list 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.