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

At issue is a reimbursement request for Lidocaine 5 percent patch. The Part D plan denied the request.We received a 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's Evidence of Coverage states, 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. The submitted documentation does not include a valid proof of purchase for the drug at issue. There is no documentation to link the prescription number on the receipt to the drug at issue. Therefore, the request for reimbursement cannot be granted.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Ciclopirox solution 8 percent to treat onychomycosis of the toenails. 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 available documentation.During this review, we requested additional information from the prescriber. Specifically, we requested information addressing the prior authorization requirements and medical records to support the enrollee has satisfied the plans prior authorization coverage criteria. We received additional information and included it in the review. The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.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 Vancomycin Hydrochloride 125 milligram capsules prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the requested drug was purchased. The plans Evidence of Coverage states that the enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined this drug was paid correctly and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Androgel 1.62 percent gel pump. The Part D plan dismissed the request and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Androgel is not on the plans formulary. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception. Therefore, the request was appropriately dismissed by the Part D plan.A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Relistor 150 milligram tablet to treat drug induced constipation. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements have not been met.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 Twirla 120/30 microgram per day patch to treat premenstrual dysphoric disorder. 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 available documentation.For the drug at issue to be covered under Medicare Part D, the manufacturer of the drug must participate in the Medicare Coverage Gap Discount Program. The manufacturer of this drug is not participating in the program. Therefore, the requested drug is excluded from Medicare Part D coverage.This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Liothyronine bulk sodium powder 15 micrograms compounded drug prescribed to treat hypothyroidism. 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. This includes the case file from the plan, and any information submitted at the reconsideration level.Drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The requested drug is considered a bulk powder/ or is consistent of bulk powder ingredients and is excluded from coverage under Part D. Liothyronine compounded capsule is not covered by the extra WRAP part of your plan. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Benzyl Alcohol liquid to be compounded into a drug to treat Parkinsons disease, Down syndrome, other seizures, and disorder of the autonomic nervous system, unspecified in an enrollee who is unable to swallow. 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 available documentation.Benzyl Alcohol liquid does not meet the definition of a Part D drug. As such, the drug is excluded from Part D coverage.  This decision does not address the medical necessity for the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Carbidopa Anhydrous powder to be compounded into a drug to treat Parkinsons disease, Down syndrome, other seizures, and disorder of the autonomic nervous system, unspecified in an enrollee who is unable to swallow. 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 available documentation.The requested drug, Carbidopa Anhydrous powder, is a bulk powder. Bulk powders do not satisfy the definition of a Part D drug and are excluded from Part D coverage. Therefore, the Carbidopa Anhydrous powder is not eligible for coverage under Medicare Part D. This decision does not address the medical necessity for the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Glycerin liquid to be compounded into a drug to treat Parkinsons disease, Down syndrome, other seizures, and disorder of the autonomic nervous system, unspecified in an enrollee who is unable to swallow. 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 available documentation.Glycerin liquid does not meet the definition of a Part D drug. As such, the drug is excluded from Part D coverage.  This decision does not address the medical necessity for the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Levodopa powder to be compounded into a drug to treat Parkinsons disease, Down syndrome, other seizures, and disorder of the autonomic nervous system, unspecified in an enrollee who is unable to swallow. 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 available documentation.The requested drug, Levodopa powder, is a bulk powder. Bulk powders do not satisfy the definition of a Part D drug and are excluded from Part D coverage. Therefore, the Levodopa powder is not eligible for coverage under Medicare Part D. This decision does not address the medical necessity for the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Polysorbate 80 liquid to be compounded into a drug to treat Parkinsons disease, Down syndrome, other seizures, and disorder of the autonomic nervous system, unspecified in an enrollee who is unable to swallow. 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 available documentation.Polysorbate 80 liquid does not meet the definition of a Part D drug. As such, the drug is excluded from Part D coverage.  This decision does not address the medical necessity for the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Stevia Extract powder to be compounded into a drug to treat Parkinsons disease, Down syndrome, other seizures, and disorder of the autonomic nervous system, unspecified in an enrollee who is unable to swallow. 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 available documentation.The requested drug, Stevia Extract powder, is a bulk powder. Bulk powders do not satisfy the definition of a Part D drug and are excluded from Part D coverage. Therefore, the Stevia Extract powder is not eligible for coverage under Medicare Part D. This decision does not address the medical necessity for the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Xanthan Gum powder to be compounded into a drug to treat Parkinsons disease, Down syndrome, other seizures, and disorder of the autonomic nervous system, unspecified in an enrollee who is unable to swallow. 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 available documentation.The requested drug, Xanthan Gum powder, is a bulk powder. Bulk powders do not satisfy the definition of a Part D drug and are excluded from Part D coverage. Therefore, the Xanthan Gum powder is not eligible for coverage under Medicare Part D. This decision does not address the medical necessity for the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Estriol-estradiol compounded cream. 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 available documentation.The requested drug is a compounded product and does not meet the definition of a Part D drug. As such, the drug is excluded from Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Testosterone 12.5 milligram per 1.25 gram (1 percent) transdermal gel to treat hypogonadism. 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 available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.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 coverage for Rizatriptan 10 milligram tablet, 36 per 30 days to treat chronic migraine. 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 available documentation.The plan's quantity limit for the requested drug is 12 per 30 days. The prescriber has provided a patient-specific clinical rationale for why the amount allowed by the plan would likely be ineffective in treating the diagnosis and/or causing harm. Specifically, on appeal, the prescriber submitted current records showing the enrollee has been treated with the requested amount with successful treatment for migraines. Micromedex's maximum daily use for this drug is 30 milligrams in 24 hours, which would be allowed per the Federal Drug Administration for safe and effective use of Rizatriptan. The submitted documentation supports the medical necessity for an exception to the plan's quantity limit for this drug. A physician reviewed the appeal and determined that the requested drug at the requested amount is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Dronabinol 2.5 milligram capsule to treat cachexia associated with cancer. 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 available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition 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 a tiering exception request for Trulicity 0.75 milligram per 0.5 milliliter pen injector to treat type 2 diabetes mellitus with hyperglycemia. 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 available documentation.Trulicity is a biologic drug on Tier 3 of the plans formulary. There are no biologic drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no 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 requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Mycophenolic Acid DR (delayed release) 180 milligram oral tablet prescribed for kidney transplant rejection prophylaxis. 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 available documentation. Additionally, we researched Medicare systems.Medicare systems show that the enrollee was eligible for Medicare Part A coverage from July 1, 2006, through February 28, 2017, and November 1, 2018, through the present. Therefore, the enrollee was eligible for Medicare Part A coverage when undergoing a kidney transplant on September 20, 2009. If the enrollee was eligible for Medicare Part A coverage on the date of the transplant, immunosuppressive drugs prescribed for transplant rejection prophylaxis would be covered under Medicare Part B. Medicare rules state that any drug available for coverage under Medicare Part B cannot be covered under Part D. Therefore, the requested drug is not eligible for Medicare Part D coverage.This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit the request for coverage through Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Leqvio 284 milligram per 1.5 milliliter solution to treat type 2 diabetes mellitus, hyperlipidemia. 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 available documentation. The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements. 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 Ozempic 0.25 milligram or 0.5 milligram dose pen to treat obesity. 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 available documentation.Drugs prescribed to treat obesity and/or to promote weight loss are excluded from the Part D coverage. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Benlysta 200 milligram per milliliter auto-injector to treat systemic lupus erythematosus. 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 available documentation.During this review, we requested additional information from the prescriber. Specifically, we requested laboratory records supporting the enrollee has satisfied the plans prior authorization coverage criteria. However, the prescriber did not respond to our request.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.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 Livalo 1 milligram tablet to treat hyperlipidemia. 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 available documentation.The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements have not been met.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 Pirfenidone 267 milligram tablet to treat the enrollee's condition. The Part D plan approved the drug requested through December 31, 2023, denied the request for a tiering exception and then auto-forwarded the case to us for review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. Pirfenidone 267 milligram tablet is included on Tier 5 of the plans formulary. Tier 5 of the formulary is the tier reserved for specialty drugs. The Specialty tier is exempt from tiered cost-sharing expectations, per Medicare rules. Therefore, this drug is not eligible for a tiering exception.  A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Cyanocobalamin 1000 microgram per milliliter solution to treat unknown diagnosis. 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 available documentation. Cyanocobalamin is a prescription vitamin. Prescription vitamin and mineral products are excluded from coverage under Medicare Part D. This is regardless of whether the vitamin or mineral product is being prescribed to correct a deficiency or to treat a disease process. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Sirolimus 0.5 milligram tablet to treat graft versus host disease. 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 available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition 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 coverage for Myrbetriq Extended Release 24-hour tablet to treat urge incontinence. 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 available documentation.Myrbetriq Extended Release 24-hour tablet is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no 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 requested drug is not eligible for a tiering exception.