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

At issue is coverage for Lubiprostone 24 microgram capsule to treat chronic idiopathic constipation. 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 requested drug is not on the plans formulary. To grant an exception for a drug not that is not on the plans formulary, alternative formulary drugs must have been tried and failed, or deemed contraindicated. The formulary alternative drugs listed by the plan in their denial letter are Bylvay, Cholbam, Cimzia, Gattex, Humira, Livmarli, Motegrity, Movantik, Ocaliva, Relistor, Simponi, Trulance, and Viberzi. However, the only drugs in the list of formulary alternatives that are indicated for the treatment of chronic idiopathic constipation, which is the condition being treated, are Motegrity and Trulance. The documentation submitted at reconsideration supports that the enrollee has tried and failed Trulance. The documentation indicates the enrollee has also tried and failed Linzess, Miralax, Metamucil, Fibercon, Senokot, Bisacodyl, and Milk of Magnesia. However, there is no indication that the enrollee has tried and failed, or has a contraindication to, the formulary alternative drug, Motegrity.Upon reopening, the prescriber has indicated that Motegrity is contraindicated for this enrollee, as the enrollee has significant psychiatric illness. The submitted medical records show that the enrollee is being treated for schizophrenia. As outlined in the Medicare approved compendium, Drugdex, Suicide attempts, suicidal ideation, and visual hallucinations have been reported with the use of Motegrity. As such, given the enrollees psychiatric illness, the use of Motegrity is contraindicated in this case. Therefore, a formulary exception is supported.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 Dicyclomine Hydrochloride 20 milligram tablet. The case was auto-forwarded by the plan. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. A request was submitted to the prescriber to provide a diagnosis, to clarify the medical history, to address the prior authorization criteria, and to provide supporting medical records. A reply from the prescriber was not received. Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for an Inpen (Novolog or Fiasp) Pink smart insulin pen to treat type 2 diabetes mellitus with hyperglycemia. The Part D plan denied the request for coverage because the Inpen Pink was not on the plans formulary and the prescriber did not sufficiently address the formulary alternative, Novopen Echo. 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 prescriber has indicated that the enrollee was approved for aspart (generic form of Novolog) cartridges to use in the Inpen. However, the Inpen is not compatible with aspart cartridges. The Inpen injector is compatible with Lilly Humalog U-100 3.0 mL cartridges, Novo Nordisk Novolog U-100 3.0 mL cartridges, and Novo Nordisk Fiasp U-100 3.0 mL cartridges. The formulary alternative, NovoPen Echo Pen, is compatible with penfill 3 mL cartridges of Fiasp, 100 units/mL (U-100) [Insulin aspart Injection] or NovoLog, 100 units/mL (U-100) [Insulin aspart Injection]. Since the enrollee has cartridges of aspart, the Inpen would not be compatible with those cartridges. The NovoPen Echo is the only delivery system of this type that uses aspart. There is no evidence that supports why the NovoPen Echo would not be as effective or has adverse effects. Based on the evidence that the enrollee already has the aspart cartridges that can only be used in the NovoPen Echo and the lack of evidence that the NovoPen Echo would not be as effective, a formulary exception is not supported.A physician reviewed the appeal and determined that the requested drug/item is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec ODT 75 milligrams (16 tablets per 30 days) to treat migraine headaches. 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 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 plan limits the amount of Nurtec ODT to 18 tablets per 30 days. The enrollee's claim history indicates 8 tablets were received on October 13, 2022. The claim at issue would exceed the plan's allowance of 18 tablets per 30 days. The prescriber has indicated the incorrect amount was requested, and the plan's allowance is sufficient. However, the QIC can only review what was submitted to the plan. To request a lower amount within the plan's limits, a new coverage determination request must be submitted to the plan for this corrected amount. 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 Skyrizi 150 milligram per milliliter syringe, 2 syringes per 30 days, to treat psoriatic arthritis. 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 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 plan limits the amount of Skyrizi 150 milligram per milliliter syringe to 6 per 365 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 coverage for Skyrizi, 2 syringe kits per 28 days, to treat plaque psoriasis. The Part D plan approved the request for the drug but denied the request for 2 syringe kits per 28 days.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 limits the quantity of the requested drug to 1 syringe kit per 28 days for the first months doses and then 1 kit per 84 days for maintenance doses. This is the amount that has been approved by the plan through the 2023 plan year. The submitted documentation does not support exceeding the plans quantity limit for the drug. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage at an amount of 2 syringe kits per 28 days.
Appeal type: Prescription Drug
Decision: Favorable

At issue is reimbursement for a Japanese Encephalitis virus vaccine, inactivated and the administration fee. 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 submitted includes the physicians bill and payment information for both the vaccine and the administration. The drug was given in the physicians office for preventive medicine indications. The drug is on the plans formulary and a valid National Drug Code was provided. Therefore, the drug is eligible for coverage.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 Irbesartan 300 milligram tablet for pain management, back. 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. As such, the Part D plan is not required to reimburse the enrollee for the cost of the drug.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 Sildenafil Citrate 20 milligram tablet for pain management, back. 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. As such, the Part D plan is not required to reimburse the enrollee for the cost of the drug.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

Fluorouracil 5 percent solution was requested to treat the enrollees 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 reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.A request was submitted to the prescriber to provide a diagnosis, to address the nonforumlary exception criteria and to provide supporting medical records. A reply from the prescriber was not received. Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aspirin 81 milligram chew tablet. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gabapentin 300 milligram capsule. The Part D plan auto-forwarded the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The enrollee is requesting reimbursement for Gabapentin given as self-administered while in the hospital. We researched Medicare resources and found that the requested drug has a National Drug Code (NDC) listed with the Food and Drug Administration (FDA), that indicates it's repackaged. Therefore, the drug is excluded from coverage under Medicare Part D and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ibuprofen 600 milligram tablet. The Part D plan auto-forwarded the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The enrollee is requesting reimbursement for Ibuprofen given as self-administered while in the hospital. We researched Medicare resources and found that the requested drug has a National Drug Code (NDC) listed with the Food and Drug Administration (FDA), that indicates it is repackaged. Therefore, the drug is excluded from coverage under Medicare Part D and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Polyethylene Glycol (PEG) 17 gram packet. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Senna laxative 8.6 milligram tablet. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 5 milligram tablet to treat benign prostatic hyperplasia without lower urinary tract symptoms. The case was auto-forwarded by the plan We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee has satisfied the plans prior authorization coverage criteria. We received additional documentation and included it in the review. 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

You requested compounded drug Diltiazem/Lidocaine 2 percent/5 percent ointment prescribed to treat the enrollees condition. 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.The plan denied your request for reimbursement because the drug does not meet the definition of a Part D drug. The National Drug Code verified with the Food and Drug Administration, that the National Drug Code numbers of the compounded drug are not valid. Therefore, the drugs are not eligible for coverage under Medicare Part D. We determined the plan is not required to provide reimbursement for the Diltiazem/Lidocaine 2 percent/5 percent ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyvanse 60 milligram capsule to treat attention deficit hyperactivity 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.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed or were contraindicated. We received additional documentation and included it in the review.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 Alprazolam ER (extended release) 0.5 milligram tablet, 30 tablets per 30 days, to treat anxiety 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(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 Methocarbamol 750 milligram tablet 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.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 Radicava ORS 105 milligram per 5 milliliter suspension to treat amyotrophic lateral sclerosis. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The 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 Roflumilast 250 microgram tablet to treat severe chronic obstructive pulmonary disease. 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. A request was submitted to the prescriber to provide medical records, to clarify the medical history, and to address the prior authorization criteria. A reply from the prescriber was not received. 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 Pregabalin 75 milligram capsule to treat chronic 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. 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 a tiering exception request for Solifenacin Succinate 10 milligram tablet to treat urge urinary incontinence, urinary frequency. 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. Solifenacin Succinate 10 milligram tablet 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 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 a tiering exception request for Januvia 50 milligram tablet to treat diabetes mellitus. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Januvia 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.