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

At issue is Toujeo Max SoloStar 300 units per milliliter subcutaneous solution pen to treat type 2 diabetes mellitus. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested a medically accepted indication, medical records, and a prescriber statement to support that all formulary alternatives were tried and failed or were contraindicated. However, we did not receive the requested information.The requested drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why 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 reimbursement request for Eliquis 2.5 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.The record shows the plan reprocessed claims for the Eliquis and adjusted the amount owed due to the enrollee's true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. The enrollee is responsible for the share of the remaining copay. We have determined that the plan is correct in its calculation of the copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Zirabev 100 milligram per 4 milliliter solution. 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 record shows the plan reprocessed claims for the Zirabev and adjusted the amount owed due to the enrollee's true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. The enrollee is responsible for the share of the remaining copay. We have determined that the plan is correct in its calculation of the copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xarelto 10 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. 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 received the requested drug as a self-administered drug in the hospital. The plans Evidence of Coverage states, 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 their share of the cost. In this case, the enrollee provided a hospital statement including the amount charged for the self-administered drug. However, proof of payment by the enrollee was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ventolin 108 microgram actuator inhaler 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 received the requested drug as a self-administered drug in the hospital. 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. In this case, the plan provided documentation showing partial reimbursement was approved, based on the contracted rate with the out of network (hospital) pharmacy for a paper claim. We determined that no further reimbursement is due.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Duloxetine Hydrochloride 30 milligram capsule 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. 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 received the requested drug as a self-administered drug in the hospital. The plans Evidence of Coverage states, 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 their share of the cost. In this case, the enrollee provided a hospital statement including the amount charged for the self-administered drug. However, proof of payment by the enrollee was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Chlorthalidone 25 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 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 received the requested drug as a self-administered drug in the hospital. The plans Evidence of Coverage states, 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 their share of the cost. In this case, the enrollee provided a hospital statement including the amount charged for the self-administered drug. However, proof of payment by the enrollee was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Atorvastatin 40 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. 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 received the requested drug as a self-administered drug in the hospital. The plans Evidence of Coverage states, 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 their share of the cost. In this case, the enrollee provided a hospital statement including the amount charged for the self-administered drug. However, proof of payment by the enrollee was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Children's Aspirin 81 milligram chewable 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, 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 Prednisolone Sodium Phosphate/Moxifloxacin Hydrochloride/Bromfenac Sodium Sesquihydrate 1/0.5/0.075 percent ophthalmic solution prescribed for cataract surgery. 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 National Drug Codes (NDCs) provided for the compounded drug are not approved by the Food and Drug Administration (FDA). Therefore, the drug is excluded from coverage under Medicare Part D and not eligible for 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: Favorable

At issue is Estring 2 milligram vaginal ring to treat postmenopausal vaginal dryness and urge incontinence. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee has satisfied the plans step therapy requirements. We received additional documentation and included it in the review.The prescriber has indicated why all alternatives required by the plan would likely not be as effective as the requested drug. The submitted documentation supports the enrollee previously trialed Premarin vaginal cream with no effectiveness. Therefore, an exception to the plans 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 Tamsulosin Hydrochloride 0.4 milligram capsule 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. 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 received the requested drug as a self-administered drug in the hospital. The plans Evidence of Coverage states, 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 their share of the cost. In this case, the enrollee provided a hospital statement including the amount charged for the self-administered drug. However, proof of payment by the enrollee was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amlodipine Besylate 5 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. 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 received the requested drug as a self-administered drug in the hospital. The plans Evidence of Coverage states, 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 their share of the cost. In this case, the enrollee provided a hospital statement including the amount charged for the self-administered drug. However, proof of payment by the enrollee was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Losartan Potassium 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 submitted documentation shows the enrollee received Losartan Potassium 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. Medicare rules state that drug claims must include a valid National Drug Code (NDC) that is listed with the Food and Drug Administration (FDA). 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 and the drugs NDC was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gabapentin 300 milligram 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 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. Medicare rules state that drug claims must include a valid National Drug Code (NDC) that is listed with the Food and Drug Administration (FDA). 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 and the drugs NDC was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metoprolol Succinate extended release 25 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 submitted documentation shows the enrollee received Metoprolol Succinate 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 Saxenda 6 milligram per 3 milliliter injection to treat morbid obesity. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed to treat weight gain (promote weight loss) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 20 milligram tablets to treat erectile dysfunction and essential hypertension. 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.At reconsideration, the enrollee states the drug is used for hypertension. Medical records were provided which document that the requested drug is being used to treat essential hypertension. 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.Additionally, 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 for the diagnosis of sexual/erectile dysfunction.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 Durezol 0.05 percent ophthalmic emulsion to treat panuveitis bilateral and cyctoid macular degeneration of the right eye. 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 Januvia 25 milligram tablet to treat 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. This drug is a Brand drug on Tier 3 of the plans formulary. There are no drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, it 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 Prolastin-C 1,000 milligram per 20 milliliter vial to treat alpha-1-antitrypsin 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.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 Ibrance 75 milligram tablets (21 tablets per 21 days, followed by 7 days off of therapy) to treat advanced breast cancer. 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 the enrollees diagnosis. The Medicare approved compendia contain a citation to support the use of the drug for the noted diagnosis. The enrollee has breast cancer that involves the chest wall. The documentation supports this is advanced breast cancer. As such, the submitted documentation supports the drug was prescribed for a medically accepted indication. The plan has prior authorization coverage criteria that must be met prior to approval. The enrollee satisfies the Plans coverage criteria. The submitted documentation supports the enrollee has HR positive/HER2 negative advanced breast cancer. The drug at issue will be used in combination with an aromatase inhibitor. The plan limits the amount of Ibrance to 21 tablets per 28 days. The requested quantity is within the plans allowed quantity limit. The prescriber has clarified the order is for 21 days of Ibrance therapy followed by 7 days off of therapy.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 Mycophenolate Mofetil 500 milligram tablets to treat pemphigus vulgaris. 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 Thalamid 50 milligram capsules to treat systemic 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.