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

At issue is Retacrit 20,000-units per milliliter to treat anemia due to chronic kidney 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 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 Estradiol 0.1-milligram per gram vaginal cream to treat atrophic vaginitis. 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.Estradiol vaginal cream is a generic drug on Tier 3 of the plans formulary. There are no 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 Tresiba FlexTouch Units-100 insulin, 100-units per milliliter (3 milliliters) subcutaneous pen-injector to treat type II diabetes mellitus. 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.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 alternative drugs provided on the plans formulary list 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 Mycophenolate Mofetil prescribed three times daily for kidney and liver transplant rejection prophylaxis. 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 also researched Medicare systems and reviewed the enrollment data available. We determined that the plan is not required to cover the drug. Medicare records indicate the enrollee received a kidney transplant, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and the requested drug is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. 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 Prolia 60 milligram prescribed for the treatment of osteoporosis with current pathological fracture. The Part D plan denied the request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation includes an Explanation of Benefits (EOB) showing coverage and payment for the requested drug was allowed by Medicare Part B. The plans Evidence of Coverage states that drugs are excluded from Part D coverage, for which payment would be available under Parts A or B. Therefore, additional reimbursement under the Part D benefit is not allowed.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 500-milligram tablets to treat peripheral ulcerative keratitis of the right cornea causing corneal inflammation. 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 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 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 Dologen K 100 tablets to treat an unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we read 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 documentation indicates the enrollee obtained the drug at issue at a pharmacy not on their plans network. In these instances, the enrollee may be responsible for paying the difference between what the enrollee paid for the drug at the out of network pharmacy and the cost that we would cover at an in network pharmacy. The documentation does not support an extreme emergency that would require the drug to be immediately supplied. This drug could have been received from a network pharmacy.We determined that the plan is not required to cover or reimburse Dologen K 100 tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fosfomic 500-milligram tablets to treat an unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we read 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 documentation indicates the enrollee obtained the drug at issue at a pharmacy not on their plans network. In these instances, the enrollee may be responsible for paying the difference between what the enrollee paid for the drug at the out of network pharmacy and the cost that we would cover at an in network pharmacy. The documentation does not support an extreme emergency that would require the drug to be immediately supplied. This drug could have been received from a network pharmacy.We determined that the plan is not required to cover or reimburse Fosfomic 500-milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tylex 750-milligram tablets to treat an unknown diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we read 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 documentation indicates the enrollee obtained the drug at issue at a pharmacy not on their plans network. In these instances, the enrollee may be responsible for paying the difference between what the enrollee paid for the drug at the out of network pharmacy and the cost that we would cover at an in network pharmacy. The documentation does not support an extreme emergency that would require the drug to be immediately supplied. This drug could have been received from a network pharmacy.We determined that the plan is not required to cover or reimburse Tylex 750-milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cinacalcet Hydrochloride 60-milligram tablets prescribed to treat post-transplant hypercalcemia due to persistent 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 requirements for this drug. These requirements must be met before coverage can be allowed. The available documentation does not satisfy the plans coverage criteria. During this review, a request was submitted to the prescriber to address the plans coverage requirements for the drug and to provide supporting medical records. The prescriber did not respond to the request. 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 Tymlos 3120-microgram per 1.56-milliliter to treat post menopausal osteoporosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The documentation satisfies the plans coverage criteria. The plan requires a fragility, vertebral, or low trauma fracture within the past five years or a bone density T-score that is -2.5 or below.  Medical records were provided which documented a T-score of -2.6 of the left hip in 2020.  Medical records also documented an intolerance to Alendronate.  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 Dronabinol 2.5-milligram capsule to treat loss of appetite and weight loss due to pulmonary infection. 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 diagnoses 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 these diagnoses. 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 Aimovig 140-milligram/milliliter to treat chronic migraine without aura, 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.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 alternative drugs provided on the plans formulary list 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 in bilateral hips status post 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.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 Ingrezza 40-milligram capsule to treat tardive dyskinesia. 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 alternative drugs provided on the plans formulary list 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 Guanfacine Hydrochloride 1-milligram tablets prescribed to control impulsivity and attention in an enrollee with autistic 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 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 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 Lidocaine 5 percent patch to treat pain in right hip. 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 to support a medically accepted ndication. 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 a tiering exception request for Jardiance 10-milligram tablets to treat diabetes. 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.Jardiance 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: Favorable

At issue is Alprazolam 1-milligram tablets to treat major depressive disorder. 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 prior authorization criteria, and to provide supporting documentation. We received additional documentation and included it in the review.The submitted documentation supports the drug was prescribed for a medically accepted indication, per the Medicare approved compendia. In addition, the plan limits the amount of Alprazolam to 120 tablets per 30 days. This is the amount of drug noted in the prescriber's office note. The requested quantity is within the plans allowed quantity limit.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 Ipratropium Albuterol 0.5-3 milligrams per 3 ampoules for nebulization 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.The documentation shows the requested drug is being administered through a nebulizer. It also notes that the enrollee is not currently residing in a long-term care facility. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover the Ipratropium Albuterol. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha SureClick 140-milligram per milliliter subcutaneous injection pen prescribed for an unspecified 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. The available documentation does not include the enrollee's diagnosis or any medical records from the prescriber. During this review, a request was submitted to the prescriber to provide the enrollees diagnosis, address the plans prior authorization requirements, and provide supporting medical records. The prescriber did not respond to the request. Without a diagnosis, it cannot be determined if the drug is being prescribed for a medically accepted indication outlined in the Medicare approved compendia. As such, the drug is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gemtesa 75-milligram tablets to treat urge incontinence. 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.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 alternative drugs provided on the plans formulary list 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 Tremfya 100-milligram/milliliter injection solution 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.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 biologic is not on the plans formulary. In order to grant an exception for the plans formulary, alternative formulary biologics must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why alternative biologics provided on the plans formulary list 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 biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Singulair 10-milligram tablets to treat asthma. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary provided for review, but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception. In addition, this is a brand drug. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis.A physician reviewer determined that tiering exception criteria are not met.