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

At issue is Dupixent 300 milligram per 2 milliliter injection solution to treat atopic 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.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. Of note, the request for a tiering exception cannot be granted as the drug has not been approved for coverage.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

Mounjaro 5 milligram per 0.5 milliliter pen 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

Budesonide 0.5 milligram per 2 milliliter suspension 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 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 Hetlioz 20 milligram capsule to treat circadian rhythm sleep disorder, free running type (Non/24). The plan denied the request.We performed 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.We requested additional information from the prescriber. Specifically, we requested your prescriber to send us a prescriber statement, answers to prior authorization coverage criteria, documented history and etiology of the enrollees sleep disorder, and medical records. However, we did not receive the documentation.Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the requested drug is not eligible for coverage under Medicare Part
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Temazepam 30 milligram capsules to treat long-term 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 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 Lidocaine 5 percent patch to treat neuropathy due to 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 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

At issue is Prograf 1 milligram capsules for the prophylaxis of rejection following 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 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: Favorable

At issue is Vraylar 1.5 milligram capsules to treat major depressive disorder. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.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 coverage criteria that must be met prior to approval. The criteria indicates the enrollee must have a Food and Drug Administration approved indication. The Medicare approved compendia contain a citation to support the use of the drug for the enrollees noted diagnosis. The Medicare approved compendium, DrugDex, contains a citation to support the use of the drug at issue as adjunctive treatment for the diagnosis of major depressive disorder. The submitted medical records support the enrollee is taking an anti-depressant in addition to the drug at issue. Therefore, an exception to the plans coverage criteria is medically necessary.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Lithobid ER (extended release) 300 milligram tablet to treat bipolar disorder. 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.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that all formulary alternatives were tried and failed, or were contraindicated. The prescriber did not respond to the request.Lithobid 300 milligram extended release tablet is not on the plans formulary. In order to grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed, or deemed contraindicated. In this case, the documentation does not support why the plans formulary alternative drugs to treat the enrollees condition would likely not be as effective and/or would likely cause adverse reactions 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 Tetanus Diphtheria and Acellular Pertussis (TDAP) vaccine and administration fee. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the vaccine was provided by the prescriber and administered in the prescribers office. The plan's Evidence of Coverage states, that if an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, proof of payment by the enrollee in the form of a receipt was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tavaborole 5 percent solution. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee purchased the requested drug and paid full price from a retail pharmacy. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, documentation was provided showing coverage was approved for the Tavaborole from January 1, 2022 through December 31, 2022. Therefore, we determined that the plan is required to reimburse the enrollee for the purchases of the drug on dates of service May 25, 2022, and September 9, 2022, based on the plan's approved amount for the drug, minus any applicable tiered copayment or coinsurance amount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Omeprazole delayed release 20 milligram capsule to treat the enrollee's condition. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Omeprazole delayed release is a generic drug on Tier 1 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 Alprazolam 1 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the request for additional reimbursement.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 that the requested drug was purchased by the enrollee for an amount that is less than or equal to the required low-income subsidy (LIS) 15 percent copayment for date of service March 21, 2022. Therefore, we determined the requested drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alprazolam 2 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the request for additional reimbursement.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 that the requested drug was purchased by the enrollee for an amount that is less than or equal to the required low-income subsidy (LIS) 15 percent copayment for date of service August 9, 2022. Therefore, we determined the requested drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clindamycin 300 milligram prescribed for an unspecified diagnosis. The Part D plan denied the request for additional reimbursement.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 that the requested drug was purchased by the enrollee for an amount that is less than or equal to the required low-income subsidy (LIS) 15 percent copayment for date of service January 27, 2022. Therefore, we determined the requested drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clotrimazole 10 milligram prescribed for an unspecified diagnosis. The Part D plan denied the request for additional reimbursement.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 that the requested drug was purchased by the enrollee for an amount that is less than or equal to the required low-income subsidy (LIS) 15 percent copayment for date of service February 1, 2022. Therefore, we determined the requested drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine 5 milligram prescribed for 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. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the requested drug was purchased on January 3, 2022. The plans Evidence of Coverage states that the enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined the cost of the drug was applied to the low income subsidy deductible appropriately, and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Desvenlafaxine extended release 25 milligram prescribed for 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. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the requested drug was purchased on January 18, 2022, and crossed into the initial coverage stage for the remaining amount. The plans Evidence of Coverage states that the enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied, and in the initial coverage stage for low-income-subsidy eligible members, the amount of copay is less than or equal to 15 percent of the drug cost. Therefore, we determined the claim was paid appropriately and further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluticasone 50 microgram spray prescribed for 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. This includes the case file from the plan, and any information submitted at the reconsideration level.The plans 2022 Evidence of Coverage states, reimbursement for drugs is based the total cost of covered drugs, minus the required deductible, copay, or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The submitted documentation shows the claim was adjusted and the enrollee was reimbursed for the cost of the drug, minus the low-income subsidy 15 percent copay. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levalbuterol Hydrofluoroalkane (HFA) 200 microgram inhaler prescribed for an unspecified diagnosis. The Part D plan denied the request for additional reimbursement.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 that the requested drug was purchased by the enrollee for an amount that is less than or equal to the required low-income subsidy (LIS) 15 percent copayment for date of service January 21, 2022. Therefore, we determined the requested drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levofloxacin 500 milligram prescribed for an unspecified diagnosis. The Part D plan denied the request for additional reimbursement.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 that the requested drug was purchased by the enrollee for an amount that is less than or equal to the required low-income subsidy (LIS) 15 percent copayment for date of service January 3, 2022. Therefore, we determined the requested drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec orally disintegrating tablet 75 milligram prescribed for 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. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the requested drug was purchased on January 23, 2022, and crossed into the initial coverage stage for the remaining amount. The plans Evidence of Coverage states that the enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied, and in the initial coverage stage for low-income-subsidy eligible members, the amount of copay is less than or equal to 15 percent of the drug cost. Therefore, we determined the claim was paid appropriately and further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ofloxacin 0.3 percent drop prescribed for an unspecified diagnosis. The Part D plan denied the request for additional reimbursement.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 that the requested drug was purchased by the enrollee for an amount that is less than or equal to the required low-income subsidy (LIS) 15 percent copayment for date of service February 1, 2022. Therefore, we determined the requested drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Olopatadine 0.6 percent prescribed for 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. This includes the case file from the plan, and any information submitted at the reconsideration level.The plans 2022 Evidence of Coverage states, reimbursement for drugs is based the total cost of covered drugs, minus the required deductible, copay, or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The submitted documentation shows the claim was adjusted and the enrollee was reimbursed for the cost of the drug, minus the low-income subsidy 15 percent copay. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Quetiapine Fumarate 25 milligram prescribed for an unspecified diagnosis. The Part D plan denied the request for additional reimbursement.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 that the requested drug was purchased by the enrollee for an amount that is less than or equal to the required low-income subsidy (LIS) 15 percent copayment for date of service January 23, 2022. Therefore, we determined the requested drug was paid correctly and no further reimbursement is required by the plan.