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

At issue is coverage for Budesonide EC (enteric coated) delayed release 3 milligram capsule to treat noninfective gastroenteritis, chronic pancreatitis, and diarrhea. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The 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 NP Thyroid 90 milligram tablets. 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 that are not approved by the Food and Drug Administration (FDA) are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucynta 100 milligram tablet to treat complex regional pain syndrome of right lower limb and lumbar radiculopathy. 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 Latuda 40 milligram tablet to treat major depressive disorder. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.A physician reviewer determined that tiering exception criteria are not met
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Humira 80 milligram per 0.8 milliliter and 40 milligram per 0.4 milliliter subcutaneous pen-injector kit to treat granuloma annulare. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The 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 Xeljanz XR (extended release) 24 hour tablets to treat dermatomyositis. 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 NP Thyroid 60 milligram tablet to treat an unspecified condition. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs that are not approved by the Food and Drug Administration (FDA) are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Corticotropin Gel 400 units per 5 milliliter injection gel to treat nephrotic syndrome. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be approved. 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 coverage for Nucynta extended release (ER) 50 milligram tablet to treat chronic pain syndrome in an enrollee with fibromyalgia and osteoarthritis. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be approved. 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 Oxycontin 20 milligram extended release tablet to treat type 2 diabetes mellitus with diabetic neuropathy, unspecified, chronic back pain. 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 Morphine Sulfate 15 milligram immediate release tablet to treat pain. 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.Morphine Sulfate 15 milligram immediate release tablet is a generic drug on Tier 4 of the plans formulary.The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Opzelura 1.5 percent cream to treat lichen planopilaris. 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 Rytary ER (extended release) 23.75/95 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 23.75/95 milligram capsule is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower tiers of the plans formulary. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewer determined that tiering exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Panzyga 10 gram per 100 milliliter solution to treat severe polyneuropathy. 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 Vemlidy 25 milligram tablet to treat chronic hepatitis B. 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 a tiering exception request for Brilinta 90 milligram tablet for the prophylaxis of thrombosis of percutaneous coronary intervention, stents. 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.Brilinta 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 Gabapentin 300 milligram capsule. 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 prescribers statement to support a diagnosis, the need for the requested medication, the enrollee has satisfied the plans prior authorization coverage criteria, and to support the quantity prescribed was medically necessary for the enrollee. However, we did not receive the requested information.The submitted documentation does not include medical records to support the diagnosis and support the need for the requested medication. 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 Invokana 100 milligram tablet to treat an unknown 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.We requested additional information from the prescriber. Specifically, we requested a medically accepted indication, medical records, and a prescriber statement to support that the enrollee has satisfied the plans step therapy requirements. However, we did not receive the requested information.No documentation was provided by the prescriber. We requested information from the prescriber but no information was received. We are not able to determine whether the requested drug(s) was prescribed for a medically accepted indication. Therefore, the drug(s) is not eligible for coverage under Medicare Part D. A physician reviewer determined that neither step therapy nor step therapy exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lorazepam 1 milligram tablet to treat anxiety disorder, unspecified. 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 to address the prior authorization criteria. However, we did not receive the requested information.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 RX0619013 00 prescribed for 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 requested the plan to provide reimbursement for RX0619013 00. The plan's Evidence of Coverage states, that if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the documentation does not include the drug name, drug dosage, quantity of drug, the National Drug Code (NDC), and the prescribing physicians name, address, and National Provider Identifier (NPI) number. Therefore, reimbursement cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Citalopram 20 milligram tablet prescribed for 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 enrollee requested reimbursement for date of fill August 25, 2022, due to paying full price at the time of purchase. The plan provided documentation showing the claim for the requested drug was approved and reimbursement was provided, based on the plan's approved amount of $0.56 minus the enrollee's copay of $0.00. We determined the plan's calculation of the enrollee's reimbursement of $0.56 was correct and no further reimbursement is due.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tibsovo 250 milligram tablet prescribed for an unspecified diagnosis. 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.The plan submitted documentation showing the enrollee was in the catastrophic coverage stage when the requested drug was purchased. The plans Evidence of Coverage states that during this stage, the cost of a covered brand name or branded generic drug will be either coinsurance of 5 percent or a copayment, whichever is the larger amount. In this case, the enrollee cost share was based on the larger amount of 5 percent coinsurance. Therefore, we determined no further reimbursement is required.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Duloxetine 30 milligram delayed release capsule prescribed for 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 enrollee is requesting reimbursement for Duloxetine given as a self-administered drug while in the hospital. However, the National Drug Codes (NDCs) provided are not listed with the Food and Drug Administration (FDA) as valid codes for the requested drug. Therefore, the drug is excluded from coverage under Medicare Part D and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Glipizide 10 milligram tablet prescribed for 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 enrollee is requesting reimbursement for Glipizide given as a self-administered drug while in the hospital. However, the National Drug Code (NDC) provided is not listed with the Food and Drug Administration (FDA) as a valid code for the requested drug. Therefore, the drug is excluded from coverage under Medicare Part D and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jantoven 7.5 milligram tablet prescribed for 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 enrollee is requesting reimbursement for Jantoven given as a self-administered drug while in the hospital. We researched Medicare resources and found that the requested drug has a National Drug Code (NDC) listed with the Food and Drug Administration (FDA) that indicates it is repackaged. Repackaged drugs are excluded from coverage under the Part D plan benefit. Therefore, the drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Losartan 50 milligram tablet prescribed for 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 enrollee is requesting reimbursement for Losartan given as a self-administered drug while in the hospital. However, the National Drug Code (NDC) provided is not listed with the Food and Drug Administration (FDA) as a valid code for the requested drug. Therefore, the drug is excluded from coverage under Medicare Part D and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metformin 500 milligram tablet prescribed for 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 enrollee is requesting reimbursement for Metformin given as a self-administered drug while in the hospital. However, the National Drug Code (NDC) provided is not listed with the Food and Drug Administration (FDA) as a valid code for the requested drug. Therefore, the drug is excluded from coverage under Medicare Part D and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pantoprazole 45 milligram delayed release tablet. 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 enrollee is requesting reimbursement for Pantoprazole given as a self-administered drug while in the hospital. We researched Medicare resources and found that the requested drug has a National Drug Code (NDC) listed with the Food and Drug Administration (FDA) that indicates it is repackaged. Repackaged drugs are excluded from coverage under the Part D plan benefit. Therefore, the drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metformin Hydrochloride 1000 milligram tablet prescribed for an unspecified diagnosis. 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. The submitted documentation does not include an Explanation of Benefits (EOB) from the primary insurance that was processed at the pharmacy for dates of fill March 21, 2022, May 7, 2022 and July 5, 2022. Therefore, without the required documentation reimbursement cannot be determined.