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

At issue is Diclofenac Epolamine 1.3 percent patch to treat acute pain due to trauma. 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 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 Flowflex COVID-19 Antigen Home Test. The Part D plan auto-forwarded 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 requested test kit is considered a non-prescription product and does not meet the definition of a Part D drug. Therefore, the requested product is excluded from coverage under the Part D benefit and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lorazepam 0.5 milligram tablets. 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. As the drug at issue has not been approved for coverage, a tiering exception cannot be granted.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 reimbursement of Dicyclomine 10 milligram capsule. 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 reimbursement through Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cephalexin 500 milligram capsule prescribed to treat an unspecified diagnosis. 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee purchased drugs from a pharmacy on a cruise ship. Drugs purchased outside of the United States are excluded from coverage. However, the cruise ship itinerary was not legible to determine if the drugs were purchased outside of the United States. The documentation submitted does not meet the required criteria. Therefore, the requested drug is not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

A reconsideration request was auto-forwarded from the plan to review the at-risk determination. The plan imposed a 90 morphine milligram equivalent (MME) restriction per day.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 record shows the enrollee filled 18 prescriptions for opioid drugs between September 22, 2021, through March 14, 2022. The prescriptions for these drugs were filled at three different pharmacies. Therefore, the plan determined a safety edit was necessary. A physician reviewed the appeal and determined the plans restriction is appropriate as there is a risk of obtaining an unsafe quantity of frequently abused drugs (i.e., opioids and benzodiazepines) when receiving prescriptions from multiple prescribers and pharmacies.In conclusion, the decision of the QIC is unfavorable.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Olmesartan/Medoxomil Hydrochlorothiazide 40/25 milligram tablet prescribed for an unspecified diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee requested the Part D plan to provide reimbursement for the requested drug purchased from a network pharmacy, and processed through the enrollee's prior Part D plan, GEHA in error. The enrollee submitted GEHA's overpayment recovery letter, which includes the copayment amounts paid by the enrollee. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Naproxen 500 milligram prescribed to treat an unspecified diagnosis. 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee purchased drugs from a pharmacy on a cruise ship. Drugs purchased outside of the United States are excluded from coverage. However, the cruise ship itinerary was not legible to determine if the drugs were purchased outside of the United States. The documentation submitted does not meet the required criteria. Therefore, the requested drug is not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prednisolone Acetate 1 percent suspension prescribed to treat an unspecified diagnosis. The Part D plan auto-forwarded 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 claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale. The plans 2022 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. 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 Fenofibrate micronized 67 milligram capsule prescribed to treat an unspecified diagnosis. 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the enrollee was in the initial coverage stage of the Part D benefit when this drug was purchased. The claim information shows the full price of the drug was less than the copay amount indicated in the plan's Evidence of Coverage. Therefore, the enrollees charge was based on the total cost of the drug. 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 Tamsulosin Hydrochloride 0.4 milligram capsule prescribed to treat an unspecified diagnosis. 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the enrollee was in the initial coverage stage of the Part D benefit when this drug was purchased. The claim information shows the full price of the drug was less than the copay amount indicated in the plan's Evidence of Coverage. Therefore, the enrollees charge was based on the total cost of the drug. 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 reimbursement request for Shingrix vaccine. The case was auto-forwarded by the plan.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 coverage for Venclexta 100 milligram tablet to treat myelodysplastic syndrome. The Part D plan denied the request due to a lack of information/documentation from the prescriber to determine if the plans coverage requirements were met. 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 include any medical records to validate that the plans requirements for coverage have been met. During this review, a request was submitted to the prescriber to address the plans coverage requirements for this drug and to provide supporting medical records to confirm that these coverage requirements were met. We received additional documentation and included it in the review. However, no medical records were submitted, as requested. Therefore, there is insufficient documentation to support that the plans prior authorization requirements have been satisfied.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 Wegovy 0.5 milligram per 0.5 milliliter pen to treat an unspecified diagnosis. 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.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 Wegovy 1 milligram per 0.5 milliliter pen to treat an unspecified diagnosis. 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.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 Wegovy 1.7 milligram per 0.75 milliliter pen to treat an unspecified diagnosis. 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.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 Wegovy 2.4 milligram per 0.75 milliliter pen to treat an unspecified diagnosis. 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.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 Botox 100 units intramuscular powder for solution to prevent chronic migraine headaches. 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 Procrit 4000 units per milliliter to treat chronic kidney disease, unspecified; anemia in chronic kidney failure, erythropoietin resistant anemia. 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 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 Acthar 80 unit per milliliter vial to treat rheumatoid arthritis. 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 Diltiazem 2 percent powder as part of a compound to treat an 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 read your 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 determined that the plan is not required to cover Diltiazem powder. According to Medicare rules, drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. Therefore, this is excluded from coverage under Part D. 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 a tiering exception request for Xarelto 10 milligram tablet to treat the enrollee's condition. 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.Xarelto 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 Cinacalcet Hydrochloride 30 milligram tablet to treat secondary hyperparathyroidism of renal origin for an enrollee with end stage renal disease on dialysis. 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. Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Sotalol 120 milligram tablet. 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.Sotalol is a generic drug on Tier 2 of the plans formulary. There are no generic drugs of the same type on the lower tiers of the plans formulary to treat the same conditions. 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 Acetaminophen 325 milligram tablet prescribed to treat an unspecified diagnosis. 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.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 Cyclobenzaprine 10 milligram tablet prescribed to treat an unspecified diagnosis. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received Cyclobenzaprine as a self-administered drug in the hospital. According to the plan's Evidence of Coverage, if the enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The enrollee provided a hospital statement including the amount charged for the self-administered drug. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Docusate Sodium prescribed to treat an unspecified diagnosis. 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.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 Gabapentin 300 milligram capsule prescribed to treat an unspecified diagnosis. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received Gabapentin as a self-administered drug in the hospital. According to the plan's Evidence of Coverage, if the enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The enrollee provided a hospital statement including the amount charged for the self-administered drug. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levoxyl 112 microgram tablet prescribed to treat an unspecified diagnosis. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received Levoxyl as a self-administered drug in the hospital. According to the plan's Evidence of Coverage, if the enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The enrollee provided a hospital statement including the amount charged for the self-administered drug. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lubricating Plus 0.5 percent eye drops prescribed to treat an unspecified diagnosis. 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.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.