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

At issue is a direct member reimbursement request for Brimonidine/Timolol 0.2 percent/0.5 percent ophthalmic solution to treat primary open angle glaucoma. 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.For self-administered drugs, these drugs may be covered under Medicare Part D. If the drug is covered by the Part D plan, the enrollee may need to pay the difference between what the hospital charged and what the plan paid in addition to any deductibles, copayments, or coinsurance the enrollee would normally pay. This amount counts towards the enrollee's Part D out-of-pocket costs. The enrollee must submit the claim to the plan for it to count towards out-of-pocket costs. If the drug isnt covered by the Part D plan, the enrollee needs to pay what the hospital charges for the drug. The Part D plan has no control over the amount hospital charges for the medication they administer.We have determined that further reimbursement is not able to be allowed.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a direct member reimbursement request for Brinzolamide 1 percent ophthalmic solution to treat primary open angle glaucoma. 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.For self-administered drugs, these drugs may be covered under Medicare Part D. If the drug is covered by the Part D plan, the enrollee may need to pay the difference between what the hospital charged and what the plan paid in addition to any deductibles, copayments, or coinsurance the enrollee would normally pay. This amount counts towards the enrollee's Part D out-of-pocket costs. The enrollee must submit the claim to the plan for it to count towards out-of-pocket costs. If the drug isnt covered by the Part D plan, the enrollee needs to pay what the hospital charges for the drug. The Part D plan has no control over the amount hospital charges for the medication they administer.We have determined that further reimbursement is not able to be allowed.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a direct member reimbursement request for Isopto Atropine 1 percent ophthalmic solution to treat primary open angle glaucoma. 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.For self-administered drugs, these drugs may be covered under Medicare Part D. If the drug is covered by the Part D plan, the enrollee may need to pay the difference between what the hospital charged and what the plan paid in addition to any deductibles, copayments, or coinsurance the enrollee would normally pay. This amount counts towards the enrollee's Part D out-of-pocket costs. The enrollee must submit the claim to the plan for it to count towards out-of-pocket costs. If the drug isnt covered by the Part D plan, the enrollee needs to pay what the hospital charges for the drug. The Part D plan has no control over the amount hospital charges for the medication they administer.We have determined that further reimbursement is not able to be allowed.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eucrisa 2 percent ointment to treat pruritis. 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 Ondansetron 8 milligram oral disintegrating tablets to treat migraine and gastroparesis. 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 Rytary 23.75/95 milligram capsule to treat Parkinson's 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.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 Eliquis 5 milligram tablet to treat atrial fibrillation. 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. Eliquis 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 Rytary ER (extended release) 61.25/245 milligram capsule to treat Parkinsons 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.Rytary ER (extended release) 61.25/245 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 Levsin 0.125 milligram sublingual tablet prescribed to treat urge incontinence. 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. Medicare records show the enrollee is no longer enrolled with the WellCare Part D plan, effective September 30, 2016. Therefore, we determined that the plan is not required to provide coverage for the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Itraconazole 100 milligram capsule to treat onychomycosis. 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. Medical records submitted at reconsideration include a stain of toenail which shows fungal elements. 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 Aquasol A 50000 unit/milliliter solution to treat vitamin A deficiency. 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 use as vitamins and minerals 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 Sodium Fluoride 1.1 percent gel for dental carries 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.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: Favorable

At issue is Nourianz 20 milligram tablet to treat Parkinson's 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. The drug at issue is not on the plans formulary. The prescriber provided patient specific clinical rationale supported by documentation, indicating why the formulary alternatives, required by the plan, would likely not be as effective as the requested drug for this diagnosis, and/or would likely cause adverse reaction(s) or other harm. Specifically, the prescriber statement and/or medical records indicate that Entacapone would not be a medically accepted indication as the patient is not on Sinemet and Selegiline is a monoamine oxidase inhibitor which should be avoided for this patient who is on Wellbutrin. Therefore, an exception to the plans formulary coverage criteria is medically necessary. 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 a tiering exception request for Rocklatan 0.02/0.005 percent opthalmic solution to treat glaucoma. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligram per 2 milliliter injection prescribed to treat eczema. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee purchased the biologic on March 9, 2022 prior to the plans approval and paid the full cost of the drug. A second fill for the biologic was purchased by the enrollee on April 19, 2022 and coinsurance was charged. According to the plans 2022 Evidence of Coverage, limits and restrictions are placed on drugs that are refilled too soon. Therefore, the claim for fill date March 9, 2022 does not qualify for reimbursement and was not applied to the true out of pocket costs. 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 a tiering exception request for Omnipod Dash Pods (Gen 4). 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.Omnipod Dash Pods is a brand drug/item on Tier 3 of the plans formulary. There are no brand drugs/items of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no brand drugs/items of the same type on a lower tier, the drug/item is not eligible for a tiering exception. A physician reviewer determined that tiering exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron 8 milligram disintegrating tablet prescribed for nausea. 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 is not eligible for coverage under Medicare Part D. This decision does not speak to the medical necessity of this drug; it speaks to whether the Part D drug plan is responsible for payment under CMS rules. 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 Armodafinil 150 milligram tablet to treat fatigue related to multiple sclerosis. 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 Dofetilide 250 microgram capsule prescribed to treat an unspecified diagnosis. The Part D plan denied the enrollees 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 that shows the claims for the requested drug were approved and 20 percent coinsurance was charged to the enrollee at the point of sale for dates of fill January 31, 2022 and April 9, 2022. The plan's 2022 Evidence of Coverage indicates the enrollee's coinsurance was based on the cost share of a standard network retail pharmacy. However, the enrollee submitted documentation showing the drug was filled on January 31, 2022 and April 9, 2022 at a preferred network retail pharmacy. The plans 2022 Evidence of Coverage shows the enrollee's cost share in the initial coverage stage and coverage gap stage for a 90 day supply of the tier 1 drug filled at a preferred network retail pharmacy is $25. Therefore, we determined that the plan is required to provide reimbursement to the enrollee minus the $25 copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 5 milligram tablet to treat erectile dysfunction status post malignant neoplasm of prostate. 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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other diagnoses for which the drug is not Food and Drug Administration (FDA) approved, 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 Wegovy 1.7 milligram per 0.75 milliliter pen to treat obesity, 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.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 Ciprofloxacin-Dexamethasone otic suspension 0.3/0.1 percent to treat otitis externa. 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 Methylphenidate Hydrochloride 10 milligram tablet to treat fatigue related to multiple sclerosis. 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 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 Temazepam 30 milligram capsule. 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 Entresto 97 milligram-103 milligram tablet to treat the enrollees 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.Entresto 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 Spiriva Respimat 2.5 microgram per actuation solution to treat pneumoconiosis due to other dust containing silica and other specified interstitial pulmonary diseases. 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 Procrit 40000 unit per milliliter solution to treat anemia in chronic kidney 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 prior authorization coverage criteria. We received additional documentation and included it in the review.The documentation satisfies the plans coverage criteria. The submitted documentation supports the enrollee has a diagnosis of anemia in chronic kidney disease. The Medicare approved compendia contain citations to support the use of the drug for this condition. Therefore, the drug is prescribed for a medically accepted indication. Furthermore, the prescriber has attested the claim at issue is for reauthorization in an enrollee that has responded to at least 12 weeks of Erythropoietin therapy. The enrollee has a current hemoglobin level of less than 12 grams per deciliter and has adequate iron stores.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.