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

At issue is Afinitor 10 milligram tablets to treat metastatic breast cancer, HR positive, HER 2 negative as subsequent therapy, in combination with Fulvestrant. 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. 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 criteria indicates the enrollee must have a Food and Drug Administration approved indication. The Medicare approved compendia contain a citation to support the use of the drug for the enrollees noted diagnosis. Furthermore, the enrollee has documentation of HER2 negative status, has progressed on anti-estrogen therapy, and the drug at issue is being used as subsequent line therapy in combination with Fulvestrant. Therefore, the plan's prior authorization criteria has been met. 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 Acidophilus extra strength tablet prescribed for stem cell transplant. 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 purchased the requested drug from an out of network pharmacy in a hospital setting. However, the documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. Medicare rules state, that Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anti-diarrheal 2 milligram tablet prescribed for stem cell transplant. 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 purchased the requested drug from an out of network pharmacy in a hospital setting. However, the documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. Medicare rules state, that Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Famotidine 20 milligram tablet prescribed for stem cell transplant. 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 purchased the requested drug from an out of network pharmacy in a hospital setting. However, the documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. Medicare rules state, that Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Melatonin 5 milligram tablet prescribed for stem cell transplant. 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 purchased the requested drug from an out of network pharmacy in a hospital setting. However, the documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. Medicare rules state, that Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omeprazole 20 milligram capsule prescribed for stem cell transplant. 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 purchased the requested drug from an out of network pharmacy in a hospital setting. However, the documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. Medicare rules state, that Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Penicillin VK 500 milligram tablet prescribed for stem cell transplant. 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 purchased the requested drug from an out of network pharmacy in a hospital setting. However, the documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. Medicare rules state, that Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prochlorperazine 5 milligram tablet prescribed for stem cell transplant. 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 purchased the requested drug from an out of network pharmacy in a hospital setting. However, the documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. Medicare rules state, that Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Scopolamine 1 milligram patches prescribed for stem cell transplant. 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 purchased the requested drug from an out of network pharmacy in a hospital setting. However, the documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. Medicare rules state, that Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sulfamethoxazole/Trimethoprim 400/80 milligram tablet prescribed for stem cell transplant. 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 purchased the requested drug from an out of network pharmacy in a hospital setting. However, the documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. Medicare rules state, that Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vitamin D3 50 microgram tablet prescribed for stem cell transplant. 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 purchased the requested drug from an out of network pharmacy in a hospital setting. However, the documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. Medicare rules state, that Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Calcitriol 0.25 microgram capsule to treat secondary hyperparathyroidism. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization coverage criteria that must be met prior to approval. The criteria indicates the enrollee must have a Food and Drug Administration approved indication. The Medicare approved compendia contain a citation to support the use of the drug for the enrollees noted diagnosis. 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 Eliquis 5 milligram tablet to treat 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.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 Breo Ellipta 100/25 microgram per blister with inhalation device 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. Breo Ellipta 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 Qulipta 30 milligram tablet to treat migraine. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cosentyx 150 milligram per milliliter pen injector to treat plaque psoriasis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 3 percent gel to treat left hip bursitis. 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 Latuda 20 milligram tablet to treat depression and anxiety. 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 Nurtec ODT 75 milligram orally disintegrating tablet to treat migraine without aura, not intractable, without status migrainosus. 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.Nurtec is included in 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 coverage at a lower-cost tier. A physician reviewer determined that tiering exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Pylera 120 milligram capsules to treat H-pylori and epigastric pain. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Pylera is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent topical patch to treat pain related to a right radical nephrectomy.  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 Vraylar 1.5 milligram capsule to treat major depressive disorder. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zilretta extended release 32 milligram intra-articular injection to treat osteoarthritis of knee. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs that are not approved by the Food and Drug Administration (FDA) are excluded from Medicare Part D coverage. According to the compendia, This drug has not been found by the  FDA to be safe and effective, and the drug product labeling has not been approved by the FDA. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ferrous Sulfate 500 milligram per 5 milliliter syrup to treat iron deficiency anemia. 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.