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

At issue is a tiering exception request for Vimpat 100-milligram tablets to treat an unspecified 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 all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.This drug/biologic is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs/biologic 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 Vitamin D (Ergocalciferol) 1.25-milligram capsules to treat vitamin D 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.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 coverage for Orphenadrine Citrate ER 100-milligram extended release tablet. 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 submitted medical records indicate the requested drug has been prescribed for the treatment of chronic neck and shoulder pain due to degenerative disc disease. However, the use of the requested drug to treat pain due to chronic musculoskeletal conditions 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 condition. Therefore, the drug is being prescribed for a non-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 Gammaplex 10 percent vial to treat other specified polyneuropathies, and idiopathic progressive neuropathy. 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 Coreg Controlled Release 80-milligram tablet to treat the enrollee's 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.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are 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 Corlanor 5-milligram tablet to treat orthostatic hypotension. 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 Saxenda 18 milligram per 3 milliliter subcutaneous solution pen injector to promote weight loss. 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: Favorable

At issue is Tymlos 3120 micrograms per 1.56 milliliter solution pen injector to treat post menopausal osteoporosis. 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 satisfies the plans coverage criteria. In the reconsideration appeal the prescriber submitted an appeal letter along with supporting office notes and the results of a DEXA scan.  The prescriber stated that the enrollee had within last 2 years:   'T12, L1, L2, L3 compression fractures and TH compression fracture diagnosed at the end of 2021 (so within the last 12 months).'  The T scores are: '-3.9 in lumbar spine and -2.6 at left femoral neck from DEXA performed 6/24/21.'  In addition,  the prescriber stated that the enrollee is not at increased risk of osteosarcoma.  The records show that the enrollee will not use the requested drug in combination with a bisphosphonate, SERM, Evenity (romosozumab-aqqg), teriparatide, Prolia (denosumab), or Xgeva (denosumab). 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 Sildenafil Citrate 25-milligram tablet to treat primary pulmonary 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. 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 Amantadine 100-milligram capsule. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the requested drug 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 documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. Therefore, reimbursement amounts cannot be determined and criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cefuroxime 250-milligram tablet. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the requested drug 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 documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. Therefore, reimbursement amounts cannot be determined and criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Donepezil 5-milligram tablet. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the requested drug 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 documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. Therefore, reimbursement amounts cannot be determined and criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is KCL 10-milliequivalent extended release capsule. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the requested drug 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 documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. Therefore, reimbursement amounts cannot be determined and criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nifedipine 30-milligram extended release tablet. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the requested drug 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 documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. Therefore, reimbursement amounts cannot be determined and criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron 4-milligram tablet. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the requested drug 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 documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. Therefore, reimbursement amounts cannot be determined and criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone APAP 5/325-milligram tablet. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the requested drug 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 documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. Therefore, reimbursement amounts cannot be determined and criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Phenazopyridine 100-milligram tablet. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the requested drug 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 documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. Therefore, reimbursement amounts cannot be determined and criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tamsulosin 4-milligram capsule. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the requested drug 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 documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. Therefore, reimbursement amounts cannot be determined and criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Valsartan 80-milligram capsule. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the requested drug 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 documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. Therefore, reimbursement amounts cannot be determined and criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5-milligram tablet to reduce the risk of stroke and systemic embolism associated with atrial fibrillation. 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. Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception. A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metaxalone 800-milligram tablet to treat muscle spasms. 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 Korlym 300-milligram tablet to treat hypercortisolism, hypertension, centralized obesity, and depression in an enrollee who does not have diabetes or glucose intolerance. 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 Nexlizet 180-10-milligram tablet to treat familial hypercholesterolemia. The additional diagnosis of coronary artery disease was submitted at reconsideration. 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 Kisqali 200-milligram tablet, 28 tablets per 28 days, to treat metastatic breast cancer, hormone receptor positive, human epidermal growth factor 2 negative. 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.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the quantity prescribed was medically necessary for the enrollee. However, we did not receive the requested information.The plan limits the amount of Kisqali to 21 tablet per 28 days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the diagnosis or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported. 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 Eliquis 5 milligram tablet to treat the enrollee's condition. 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. Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception. A physician reviewer determined that the tiering exception criteria are not met.