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

At issue is Klor-Con M20 20 MEQ tablet ER prescribed for unknown 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 record shows the enrollee requested the plan to provide reimbursement for the Klor-Con M20. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the Klor-Con M20. Please submit your request to Medicare Part A. 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

At issue is Levothyroxine Sodium 88 microgram tablet prescribed for unknown 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 record shows the enrollee requested the plan to provide reimbursement for the Levothyroxine Sodium. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the Levothyroxine Sodium. Please submit your request to Medicare Part A. 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

At issue is Loratadine 10 milligram tablet 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 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 record shows the enrollee received Loratadine as a self-administered drug while inpatient in the hospital. According to Medicare rules, drugs that are considered over-the-counter are excluded from coverage under Part D. Loratadine is an over-the-counter medication. There is no evidence that the enrollee has supplemental coverage for the drug. Therefore, we determined that the Part D plan is not required to cover or reimburse the enrollee for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Losartan 50 milligram tablet prescribed for unknown 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 record shows the enrollee requested the plan to provide reimbursement for the Losartan. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the Losartan. Please submit your request to Medicare Part A. 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

At issue is Metoprolol Succinate 25 milligram tablet ER 24HR prescribed for unknown 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 record shows the enrollee requested the plan to provide reimbursement for the Metoprolol Succinate. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the Metoprolol Succinate. Please submit your request to Medicare Part A. 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

At issue is Pantoprazole 20 milligram tablet prescribed for unknown 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 record shows the enrollee requested the plan to provide reimbursement for the Pantoprazole. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the Pantoprazole. Please submit your request to Medicare Part A. 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

At issue is Tramadol HCL 50 milligram tablet prescribed for unknown 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 record shows the enrollee requested the plan to provide reimbursement for the Tramadol. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the Tramadol. Please submit your request to Medicare Part A. 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

At issue is Vitamin B-12 1000 microgram tablet 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 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 record shows the enrollee received Vitamin B-12 as a self-administered drug while inpatient in the hospital. According to Medicare rules, Vitamins and minerals that are considered over-the-counter are excluded from coverage under Part D. Vitamin B-12 is an over-the-counter medication. There is no evidence that the enrollee has supplemental coverage for the drug. Therefore, we determined that the Part D plan is not required to cover or reimburse the enrollee for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vitamin D 25 microgram 1000(UT) tablet 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 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 record shows the enrollee received Vitamin D as a self-administered drug while inpatient in the hospital. According to Medicare rules, Vitamins and minerals that are considered over-the-counter are excluded from coverage under Part D. Vitamin D is an over-the-counter medication. There is no evidence that the enrollee has supplemental coverage for the drug. Therefore, we determined that the Part D plan is not required to cover or reimburse the enrollee for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estradiol 0.01% cream prescribed for an unknown diagnosis. 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 record shows the plan reprocessed the enrollees claim for the Estradiol and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan adjusted the copayment because Medicare records indicate the enrollee did not qualify for low income subsidy copay level. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the remaining copay. We have determined that the plan is correct in its recalculation of the enrollees copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Xtampza 13.5 milligram capsules prescribed for other spondylosis, lumbar region. The Part D plan denied the request. We performed 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. We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the formulary alternatives were tried and failed. However, we did not receive the requested information.The submitted documentation did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Latuda 60 milligram tablets prescribed for the treatment of bipolar 1 disorder, depressed type. 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. Latuda is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. 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 reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Zarxio 480 microgram per 0.8 milliliter subcutaneous injection syringe prescribed for the treatment of neutropenia. 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. Zarxio is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. During this review, a request was submitted to the prescriber to address the alternative medications included in the plans formulary and to provide supporting medical records. The prescriber did not respond to the request. Therefore, the formulary exception criteria have not been met. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Durera 100-5-micromgram Inhaler to treat mild intermittent asthma. The Part D plan denied the request. The requested drug is not on the plans formulary. 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.We asked your prescriber to send us a prescriber statement, a medically accepted indication (diagnosis), answers to prior authorization coverage criteria, and medical records. However, we did not receive the documentation.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 medical records do not support why other drugs on the plans formulary would not work for you.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 Lidocaine 5% patch prescribed to treat the enrollees condition. The Part D plan denied the appeal 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.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs the requested drug. We did not receive the requested documentation.The appeal request is for Lidocaine 5% patch. Upon redetermination, the Part D plan denied the request stating that the provided diagnosis (back pain with a history of compression fractures) was a non-medically accepted indication. There are no medical records provided supporting the enrollees condition and to determine if the enrollee has met the criteria for a medically acceptable indication per the approved Medicare compendia.A physician reviewed the appeal and determined that the plan is not required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Fentanyl 75 microgram per hour transdermal 72-hour patch prescribed for chronic pain. 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 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 Part D plan has prior authorization requirements that have to be met before coverage of this drug is allowed. It is not possible to confirm that the plans coverage criteria have been satisfied with the available documentation. During this review, a request was submitted to the prescriber to address the plans prior authorization requirements and to provide supporting medical records. The prescriber did not respond to the request. As such, the plans prior authorization criteria have not been validated. 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 Prolia 60-milligrams/milliliter Solution Prefilled Syringe to treat illness, unspecified. The Part D plan denied the request. We performed 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.We asked your prescriber to send us a prescriber statement, a medically accepted indication, answers to prior authorization coverage criteria, lab reports, diagnostic reports, and medical records. We received the documentation and included it in our review.At reconsideration, a diagnosis of age-related osteoporosis without current pathological fracture (M81.0) was given. However, the documentation provided addressed the plans coverage criteria, and those criteria were not 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 Venclexta 100 milligram tablets prescribed for myelodysplastic syndrome. The Part D plan denied the request. We performed 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 submitted documentation indicates the prescriber ordered the drug at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There are no Medicare approved journal articles to support the use of the drug for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Tadalafil 5 milligram tablets. 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 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 documentation indicates that the enrollee has been taking Tadalafil for the treatment of benign prostatic hyperplasia with lower urinary tract symptoms. This is a medically accepted indication for the use of Tadalafil noted in the Medicare approved compendia. However, the records indicate that the enrollee has been taking Tadalafil for benign prostatic hyperplasia for more than 26 weeks. As outlined in the Medicare approved compendia, the cited duration of therapy with Tadalafil to treat benign prostatic hyperplasia is up to 26 weeks. The compendia do not contain any citations to support the use of Tadalafil to treat benign prostatic hyperplasia for beyond 26 weeks of therapy. Therefore, the requested drug, as prescribed, is being used for a non-medically accepted indication. As such, the drug is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Rocklatan 0.02-0.005% ophthalmic solution prescribed for the treatment of open-angle glaucoma. 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 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. Rocklatan 0.02-0.005% ophthalmic solution is not included in the plans formulary. The prescriber has not provided sufficient patient specific clinical rationale as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. During this review, a request was submitted to the prescriber to address the alternative medications included in the plans formulary. The prescriber did not respond to the request. Medical records submitted do not address all formulary alternatives. Therefore, the formulary exception criteria have not been met. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Fenofibrate 54-milligram tablet to treat an unknown 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 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.Fenofibrate 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 condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Clonazepam 1 milligram tablet prescribed 120 for 30 days for panic attacks. The Part D plan denied your 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 asked the prescriber to send us information regarding the enrollee's condition. We also asked for medical records or other documentation to show why the enrollee needs this amount of the medication. We did not receive the documentation requested.The documentation shows Clonazepam was prescribed to treat panic attacks. However, we did not receive medical records and the prescribers statement does not support why an exception to the plans quantity limit is medically necessary. A physician reviewed your appeal and determined that the plan is not required to cover Clonazepam, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Opsumit 10 milligram tablets prescribed as directed for pulmonary arterial hypertension. The Part D plan denied your 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. 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 medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Opsumit.