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

At issue is Trazodone 100 milligram tablet prescribed for unknown 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 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 submitted documentation shows the requested drug was given as a self administered drug purchased by the enrollee from an out-of-network pharmacy(hospital). The National Drug Code was provided by the enrollee for the requested drug. However, it is not listed with the Food and Drug Administration as a valid code. Therefore, we determined the plan is not required to provide reimbursement. This decision does not concern 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 Vitamin D3 25 milligram tablet to treat unknown 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.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 Eliquis 5-milligram tablet for anticoagulation. 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.  Relevant medical records were requested but not provided.  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: Favorable

At issue is Aubagio 14-milligram tablets to be taken daily for the treatment of relapsing multiple sclerosis. The Part D plan denied the request for coverage because the drug was not on the formulary and the documentation did not support the enrollee tried and failed at least two of the required formulary alternative drugs. 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.At reconsideration, the prescriber has submitted a prescriber statement to confirm the enrollee has tried and failed two of the formulary alternative drugs, Copaxone and Rebif. The prescriber notes that the enrollee has been stable on the requested drug for three years and that there is a risk of relapse with a change in medications. Therefore, the documentation submitted at reconsideration supports a formulary exception.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 Freestyle Libre prescribed for diabetes. 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 Trumixa 500-milligrams/50-milliliters Vial to treat Immunoglobulin G4-related 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 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 a tiering exception request for Combigan 0.2-percent-0.5-percent eye drops to treat open angle glaucoma with borderline findings. 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.Combigan 0.2-percent-0.5-percent eye drops is a brand drug on Tier 2 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 Aminopyridine powder compounded drug prescribed for 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 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 determined that the plan is not required to cover the requested 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 considered a bulk powder and 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 Cyclobenzaprine Hydrochloride 10-milligram tablets to treat chronic spasmodic torticollis. 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 reimbursement for a Boostrix TDAP vaccine and administration fee. 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. The receipt is provided that supports a total of $155.00 was paid by the enrollee for immunization with a Boostrix TDAP vaccine and the administration fee on the date of June 22, 2021. The correct National Drug code was also submitted. The documentation is sufficient to support the medical necessity of the vaccine and reimbursement for the shingles vaccine. Therefore, reimbursement can be made.
Appeal type: Prescription Drug
Decision: Favorable

At issue is reimbursement for a Shingrix vaccine and administration fee. 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. The receipt is provided that supports a total of $303.00 was paid by the enrollee for immunization with a shingles vaccine and the administration fee on the date of June 22, 2021. The correct National Drug code was also submitted. The documentation is sufficient to support the medical necessity of the vaccine and reimbursement for the shingles vaccine. Therefore, reimbursement can be made.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Radicava 30-milligrams/100-milliliter Bag to treat Amyotrophic Lateral 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 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: Favorable

At issue is Nuzyra 150-milligram tablets to treat a Mycobacterium abscesses lung infection. The Part D plan denied the request for coverage because the drug was being used for a non-medically accepted indication. 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.As outlined in the Medicare approved compendium, DrugDex, the Food and Drug Administration (FDA) has granted orphan drug status to Nuzyra for the treatment of infections caused by nontuberculous mycobacteria. The enrollees lung infection has been caused by Mycobacterium abscesses, which is a nontuberculous mycobacteria. Therefore, the drug is being used for a medically accepted indication. The plans quantity limit for the drug is 30 tablets for a 14-day supply. However, the prescriber has requested coverage for a 30-day supply of the drug. There is no recommended dosing in DrugDex for the use of Nuzyra in the treatment of non-tuberculous mycobacteria. However, the submitted medical records support an exception to the plans quantity limit of a 14-day supply. As such, coverage can be allowed for the requested drug at the requested dosage.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 Silodosin 8-milligram capsule to treat benign prostatic hyperplasia with lower urinary tract symptoms. 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, answers to off-formulary coverage criteria, and a prescriber statement to support that all formulary alternatives were tried and failed or were contraindicated. However, we did not receive the documentation.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

You requested Avycaz 2.5-gram/100-milliliter for solution to treat osteomyelitis. 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. 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 Zejula 100-milligram capsule for maintenance in enrollee with advanced ovarian cancer status post-surgery, chemotherapy, and Avastin. 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 indicates the prescriber ordered the drug at issue for maintenance in an enrollee with advanced ovarian cancer. Enrollee had been receiving Avastin maintenance which will be ending and maintenance with Zejula is now requested.The plan has prior authorization coverage criteria that must be met prior to approval. The enrollee satisfies the Plans coverage criteria. Per the documentation submitted, the enrollee has a diagnosis of advanced ovarian cancer, the drug will be used for maintenance, the enrollee had complete response to platinum therapy, is 18 years old or older, and the drug is given with oncologist recommendations. It is noted that for continuation of this drug it is important the enrollee maintain complete remission.  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 Otezla 30-milligram tablets to treat plaque psoriasis and psoriatic 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 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 Humira CF 80-milligram/40-milligram pen injector to treat pyoderma gangrenosum. 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 biologic 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 biologic, as prescribed, for the treatment of this diagnosis. Therefore, the requested biologic is not eligible for coverage under Medicare Part D.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 Cosentyx 150-milligram/milliliter subcutaneous injection pen to treat plaque psoriasis and psoriatic 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 plan has prior authorization requirements for this biologic. 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 biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Acetaminophen-Codeine #3 300-30-milligrams tablet to treat pain and inflammation/swelling around the lungs. 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.Acetaminophen-Codeine #3 300-30-milligrams tablet is a generic drug on Tier 3 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 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 Ondansetron Hydrochloride 4-milligram tablets to treat nausea and vomiting due to Crohn's disease and bowel obstructions. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Levothyroxine 88 microgram capsule to treat the enrollee's 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.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all lower-tier drugs to treat the enrollees condition were tried and failed or were contraindicated. However, we did not receive the requested information.Levothyroxine Sodium 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/biologic is not eligible for a tiering exception.A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

Ondansetron HCL 4 milligram tablet was requested to treat the enrollees condition. The Part D plan denied your request because medical necessity was not established. As well, the requested drug has prior authorization criteria. 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 were unable to reach the prescriber by fax or phone to provide a diagnosis, and to address the prior authorization criteria. Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Enterade prescribed to treat radiation sickness. 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.According to Medicare rules, drugs that are considered a medical food are excluded from coverage under Part D. The plan indicates that supplemental coverage is not provided under the Part D benefit for this drug. Therefore, we determined that the Part D plan is not required to cover the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil 20-milligram tablet to treat pulmonary hypertension, 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 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. 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 Shingrix vial kit prescribed for shingles vaccination. 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 vaccine was provided by the prescriber and administered in the prescribers office. The plan's Evidence of Coverage states, that if an 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. However, proof of payment by the enrollee in the form of a receipt was not provided. Therefore, reimbursement criteria has not been met.