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

At issue is Levothyroxine 175 microgram tablets to treat the enrollee's diagnosis. The Part D plan denied the request for a tiering exception.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.This drug is included on Tier 1 of the plans formulary. There are no cost-sharing tiers lower than Tier 1; therefore, a tier exception cannot be considered. A physician reviewed your appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Genotropin12 milligram subcutaneous cartridge to treat human growth hormone 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.This biologic is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier biologic drugs 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 a tiering exception request for Dutasteride/Tamsulosin 0.5/0.4 milligram capsule to treat benign prostatic hyperplasia. 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.Dutasteride/Tamsulosin 0.5/0.4 milligram capsule is a generic drug on Tier 1 of the plans formulary. There are no lower tiers on the plan's formulary. 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 Eliquis 5 milligram tablets as anti-coagulation therapy for the prophylaxis of cerebral vascular accident and systemic embolism in an enrollee 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 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 Droxidopa 200 milligram capsule prescribed for orthostatic hypotension caused by diabetic autonomic 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 is not eligible for coverage under Medicare Part D. This decision does not speak to the medical necessity of this drug; it speaks to whether the Part D drug plan is responsible for payment under the Centers for Medicare and Medicaid Services (CMS) rules. 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 Ipratropium Bromide 0.2 milligram per milliliter solution to treat 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. Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness 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 Movantik 25 milligram tablet to treat opioid-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 documentation submitted.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 Pradaxa 150 milligram capsule prescribed for cerebrovascular accident, not indicated as embolic from 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 medication you are requesting is in unit dose packaging. Unit dose medications are prepared and dispensed in individual labeled dose packets. Under your plan, unit dose packaging is notcovered unless being used during a hospital or clinic observation stay. Coverage cannot be authorized at this time. Prescriber statement was received and reviewed, and does not justify an exception.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 Icosapent Ethyl 0.5 gram capsule to treat hypertriglyceridemia in an enrollee with a triglyceride level of 358 milligram per deciliter and 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 a tiering exception request for Vraylar 3 milligram capsule, 30 capsules per 30 days, to treat moderate depressed bipolar I 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. This drug is being provided by the plan at the cost-sharing level of the Specialty tier. Specialty tier drugs 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 Trulicity 0.75 milligram per 0.5 milliliter pen to treat hyperglycemia with abnormal weight gain. 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 the enrollee has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information.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 Venlafaxine Hydrochloride extended release 75 milligram tablet to treat major depression. 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 all formulary alternatives were tried and failed or were contraindicated. However, we did not receive the requested information.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 Lidocaine 5 percent patch to treat pain due to a thoracic wedge compression fracture. 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 Repatha Sureclick 140 milligram per milliliter injection solution to treat hyperlipidemia in an enrollee with atherosclerotic heart disease of native coronary artery without angina pectoris. 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 Crestor 5 milligram tablet 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.We requested additional information from the prescriber. Specifically, we requested a medically accepted indication, medical records, and a prescriber statement to support that all lower-tier drugs to treat the enrollees condition were tried and failed or were contraindicated and that the enrollee has satisfied the plans step therapy requirements. We received additional documentation and included it in the review.The prescriber has not indicated that all alternatives required by the plan have been tried and failed, or why the plans required step therapy drugs would likely not be as effective as the requested drug. Additionally, because Crestor is denied, a tiering exception cannot be considered. A physician reviewer determined that neither step therapy nor tiering exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Salsalate 750 milligram tablet to treat rheumatoid 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 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 Metoclopramide Hydrochloride 10 milligram tablet prescribed for pain. 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 submitted documentation shows the enrollee filled a prescription for the requested drug at a compounding pharmacy. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron Hydrochloride 8 milligram tablet prescribed for pain. 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 submitted documentation shows the enrollee filled a prescription for the requested drug at a compounding pharmacy. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec ODT (orally disintegrating tablet) 75 milligram tablet to treat chronic migraine without aura, intractable without status migrainosus. 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 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 Vyzulta 0.024 percent ophthalmic solution to treat primary open angle glaucoma of both eyes, moderate stage. 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 2022 formulary. In order to grant an exception for a drug not on the plans 2022 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 Atorvastatin 10 milligram tablet prescribed for an unspecified diagnosis. 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 plans 2022 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. The plan submitted documentation that shows the enrollee was in the initial coverage stage when the drug was purchased. The claims for a 31 day supply of the tier 1 drug were approved and a copay of $5.00 was charged to the enrollee at the point of sale for dates of fill May 2, 2022, July 2, 2022 and August 2, 2022. We determined the copay was calculated correctly, based on the enrollee's cost sharing stage for a 31 day supply of a tier 1 drug purchased at a network pharmacy. Therefore, no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buspirone Hydrochloride 15 milligram tablet prescribed for an unspecified diagnosis. 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 plans 2022 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. The plan submitted documentation that shows the enrollee was in the initial coverage stage when the drug was purchased. The claims for a 30 day supply of the tier 1 drug were approved and a copay of $4.80 was charged to the enrollee at the point of sale for dates of fill April 2, 2022, June 2, 2022, September 2, 2022, and November 2, 2022. The claims for a 30 day supply of the tier 1 drug were approved and a copay of $5.00 was charged to the enrollee at the point of sale for dates of fill August 2, 2022, October 2, 2022 and December 2, 2022. We determined the copay was calculated correctly, based on the enrollee's cost sharing stage for a 30 day supply of a tier 1 drug purchased at a network pharmacy. Therefore, no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Breo Ellipta 200-25 microgram blister powder with device prescribed for an unspecified diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee was in the catastrophic coverage stage when the requested drug was purchased. The plans Evidence of Coverage states that during this stage, the cost of a covered drug will be either coinsurance of 5 percent or a copayment, whichever is the larger amount. In this case, the plan approved amount for the drug was $35.83 and the enrollee cost share of $9.85 was based on the larger amount of copay. Therefore, the enrollee was reimbursed the remaining $25.98. We determined that the plan calculated the coinsurance correctly and no further reimbursement is required.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Breztri Aerosphere 160/9/4.8 microgram per actuation inhaler to treat severe persistent asthma and 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.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 coverage for Mounjaro 12.5 milligram per 0.5 milliliter pen-injector to treat prediabetes and 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 documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The noted conditions are off-label uses for the requested drug. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. Therefore, the drug is being prescribed for non-medically accepted indications. Additionally, it should be noted that drugs prescribed to treat obesity/promote weight loss are excluded from Part D coverage. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.