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

At issue is Glumetza extended release 500 milligram tablet prescribed for an unknown diagnosis. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale. We determined the plan is correct in its calculation of additional copay amounts due to reconciliation of the enrollees true out of pocket accumulation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Indapamide 1.25 milligram tablet prescribed for an unknown diagnosis. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale. We determined the plan is correct in its calculation of additional copay amounts due to reconciliation of the enrollees true out of pocket accumulation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Klor-Con 10 milligram tablet prescribed for an unknown diagnosis. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale. We determined the plan is correct in its calculation of additional copay amounts due to reconciliation of the enrollees true out of pocket accumulation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omeprazole delayed release 40 milligram capsule prescribed for an unknown diagnosis. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale. We determined the plan is correct in its calculation of additional copay amounts due to reconciliation of the enrollees true out of pocket accumulation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Terazosin Hydrochloride 10 milligram capsule prescribed for an unknown diagnosis. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale. We determined the plan is correct in its calculation of additional copay amounts due to reconciliation of the enrollees true out of pocket accumulation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 50 milligram/5 gram prescribed for an unknown diagnosis. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale. We determined the plan is correct in its calculation of additional copay amounts due to reconciliation of the enrollees true out of pocket accumulation.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Stivarga 40-milligram tablets, 84 tablets per 28 days, to treat metastatic colon cancer. The Part D plan denied the request because the plans prior authorization requirements were not met. 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.As outlined in the prior authorization requirements, the enrollee must have metastatic colorectal cancer; the enrollee must have experienced disease progression, intolerance, or contraindication with all of the following therapies: Fluoropyrimidine (regimens include 5-Fluorouracil [5-FU]/Capecitabine); Oxaliplatin-based chemotherapy; Irinotecan-based chemotherapy, and anti-vascular endothelial growth factor (VEGF) therapy. Finally, if the colorectal cancer is RAS wild type (WT), the enrollee must have experienced disease progression, intolerance, or contraindication with anti-epidermal growth factor receptor (EGFR) therapy. The medical records indicate the enrollee has metastatic colorectal cancer and that the requested drug will be used as monotherapy. Additionally, the documentation shows that the enrollees cancer progressed after taking 5FU and Irinotecan. The documentation shows that the enrollee had a myocardial infarction due to the administration of Oxaliplatin and the enrollee has a contraindication to the anti-VEGF drug, Avastin, due to location of the tumor increasing the enrollees risk of gastrointestinal hemorrhage. Finally, the medical records indicate that the enrollees cancer is not RAS WT and anti-EGFR treatment is not applicable in this case. Therefore, the submitted documentation supports that the plans coverage requirements have been met. The plans quantity limit for this drug is 84 tablets per 28 days, which is what the prescriber has requested. As such, coverage for the drug can be allowed.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 Zubsolv 8.6/2.1-milligram sublingual tablets to treat lumbar radiculopathy and back 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 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 140-milligram/milliliter Sureclick with a quantity of six ( 6 x 140 mg/1 ml) every thirty days to treat mixed hyperlipidemia. 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 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 Repatha 140-milligram/milliliter to three ( 3 x 140 mg/1 ml) every thirty 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 Rinvoq Extended Release 15-milligram tablets 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.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 required by the plan, 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 Modafinil 200-milligram tablets to treat stimulant use disorder, severe. 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 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 Xiidra 5-percent ophthalmic dropperettes to treat dry eye syndrome of bilateral lacrimal glands. 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.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 reactions or other harm. During this review, a request was submitted to the prescriber to address the alternative medications included in the plans formulary and to provide supporting medical records. The prescriber did not respond to the request. Therefore, the formulary exception criteria have not been met. 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 Mycophenolate Mofetil 200-milligram/milliliter suspension reconstituted for an enrollee status post a kidney transplant. 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 (ORGAN) 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 Codeine Sulfate 30-milligram tablets to treat other intervertebral disc degeneration, lumbar region. 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 Tacrolimus 0.1 percent ointment to treat allergic contact dermatitis. 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 Diclofenac 35-milligram capsules to treat arthritis pain. 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.For the drug at issue to be covered under Medicare Part D, the manufacturer must participate in the Medicare Coverage Gap Discount Program. This manufacturer is not participating in the program. Therefore, the drug is excluded from Part D coverage.This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rinvoq ER 15 milligram tablet 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 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 Gralise 600-milligram ER tablets to treat disorders of trigeminal nerve (trigeminalneuralgia). 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: Favorable

At issue is Repatha Sureclick 140-milligram/milliliter pen injector with a quantity of 2 pens per 28 days to treat hyperlipidemia. 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 address the prior authorization criteria and to provide supporting medical records. We received additional information and included it in this review. The documentation satisfies the plans coverage criteria for reauthorization of this drug. The documentation submitted supports this is reauthorization for the requested drug. The laboratory studies have been submitted that show an LDL-C reduction while on Repatha therapy from baseline.  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Eszopiclone 3-milligram tablets to treat insomnia. 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 drug at issue is not on the plans formulary. The prescriber provided patient specific clinical rationale supported by documentation, indicating why the formulary alternatives, required by the plan, would likely not be as effective as the requested drug for this diagnosis, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary 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 Bystolic 5 milligram tablet to treat 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 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  required by the plan, 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 Eszopiclone 2 milligram tablet to treat insomnia. 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 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 Nexletol 180-milligram tablets to treat hypercholesterolemia. 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 Levothyroxine 0.4 microgram compounded drug prescribed for unknown diagnosis. The plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed 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.According to Medicare rules, drugs that fall into the category of bulk powders are excluded from coverage under Part D. Therefore, the requested drug does not meet the definition of a Part D drug. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit