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

At issue is coverage for Temazepam 15 milligram capsule. The Part D plan denied the request for coverage due to a lack of response/information from the prescriber. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The documentation submitted at reconsideration indicates that the requested drug has been prescribed for the treatment of short-term insomnia. This is a medically accepted indication for the drug outlined in the Medicare approved compendia. However, the plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not confirm that the plans requirements for coverage have been satisfied, as no medical records have been submitted to validate the marked answers on the completed prior authorization form that has been submitted at reconsideration. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.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 First-Mouthwash BLM bulk powder prescribed for leukoplakia. The Part D 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 determined that the plan is not required to cover First Mouthwash BLM bulk powder. Drugs compounded from bulk powders are not Food and Drug Administration approved and are therefore not covered under Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Ondansetron Hydrochloride 4 milligram tablet. The Part D plan denied the request for coverage and then 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 submitted documentation indicates that the requested drug has been prescribed to treat nausea and vomiting due to end stage liver disease and esophagitis. However, 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 for the treatment of nausea and vomiting that is due to the presence of end stage liver disease and/or esophagitis. Therefore, the drug is being prescribed for a non-medically accepted indication(s).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 Xtampza ER (extended release) 36 milligram capsule to treat chronic pain syndrome. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why all of the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not indicate that the enrollee has tried and failed all of the suggested formulary alternative drugs. As such, the formulary exception criteria have not been met.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 Trulance 3 milligram tablets to treat gastroesophageal reflux disease without esophagitis . 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 Wegovy 0.25 milligram per 0.5 milliliter pen injector to treat obesity. 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.Drugs prescribed to treat weight gain (promote weight loss) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from 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

At issue is Flector 1.3 percent patch to treat chronic pain in an enrollee with fibromyalgia and osteoarthritis. 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 Ozempic 0.25 or 0.50-milligram dose subcutaneous solution pen injector to treat type 2 diabetes mellitus. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level. Ozempic 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: Unfavorable

At issue is a tiering exception request for Modafinil 200 milligram tablet for the adjunctive treatment of depression. 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. Modafinil is a generic drug on Tier 3 of the plans formulary.  The prescriber has not indicated if all alternatives required by the plan have been tried and failed or why the plans lower-tiered drugs would likely not be as effective as the requested drug. Therefore, this drug is not eligible for a tiering exception. A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Inlyta 5 milligram tablets to treat metastatic sinonasal mucosal melanoma. 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 indicates the prescriber ordered the drug at issue for the enrollees diagnosis. The prescriber submitted a Medicare approved journal article to support the use of the drug for this condition. The European Journal of Cancer, a Medicare accepted journal, has an article titled 'Real-world efficacy and safety of Axitinib in combination with anti-programmed cell death-1 antibody for advanced mucosal melanoma.' This journal indicates that anti-PDL1 therapy is recommended in enrollees with sinonasal mucosal melanoma. As such, the submitted documentation supports the drug was prescribed for a medically accepted indication. The plan has prior authorization coverage criteria that must be met prior to approval. The enrollee satisfies the Plans coverage criteria. 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. 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 Vancomycin Hydrochloride 125 milligram capsule. The Part D plan auto forwarded the request.We received the submitted documentation to perform an independent and de novo review.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support a diagnosis and the enrollee has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. 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 Clobetasol 0.05 percent cream to treat an unknown condition in an enrollee. The Part D plan auto-forwarded the request.We received the submitted documentation to perform an independent and de novo review.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support a diagnosis and all formulary alternatives were tried and failed or were contraindicated by the enrollee. However, we did not receive the requested information.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. 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/Prilocaine 2.5/2.5 percent cream with a quantity of 30 per 10 days. 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 submit medical records supporting the medical diagnosis and medical history, to provide supporting medical records, and to address the quantity limit criteria. 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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine 5 milligram tablet. The Part D plan auto forwarded the request.We received the submitted documentation to perform an independent and de novo review.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support a diagnosis and the enrollee has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. 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 Ciclopirox 8 percent solution. The Part D plan denied the request.We received the submitted documentation to perform an independent and de novo review.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 submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. 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 Lubiprostone 24 microgram capsule. The Part D plan denied the request.We received the submitted documentation to perform an independent and de novo review.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support a diagnosis and that all formulary alternatives were tried and failed or were contraindicated. However, we did not receive the requested information.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. 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 Xarelto 10 milligram tablet for prophylaxis of thromboembolism in an enrollee with history of saddle pulmonary embolism. 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 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 Estradiol/Vitamin E Acetate in Versabase 0.02 percent compound cream prescribed for an unspecified diagnosis. 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 is requesting reimbursement for the compound drug purchased at an out-of-network 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 compound drug was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Herpes Zoster (HZV) vaccine Recombinant and administration fee. The Part D plan auto-forwarded the request for reimbursement. 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 shows the enrollee received the vaccine at their physicians office. Payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or provider's office. The enrollee submitted documentation to the plan that includes a reimbursement request, a copy of an itemized bill, and a credit card receipt. However, the documentation does not show that the bill was paid in full. Therefore, we determined that the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Morphine Sulfate ER 15 milligram tablets. The Part D plan denied the request.We received a 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 plan's Evidence of Coverage states, 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. The submitted documentation does not include a valid proof of purchase for the drug at issue. Therefore, the request for reimbursement cannot be granted.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Durezol prescribed for an unknown diagnosis. 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 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 carefully reviewed the record, the plans formulary and Evidence of Coverage. In this case, there is no evidence to support that the plan issued a recovery notice within 45 days of the plans receipt of complete information regarding the claims adjustment. The documentation shows the date of the recovery notice to the enrollee is January 30, 2023, more than 45 days after the plan's receipt of completed information regarding the claims adjustment on November 14, 2022.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Hydrocodone Bitartrate/Acetaminophen prescribed for an unknown diagnosis. 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 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 carefully reviewed the record, the plans formulary and Evidence of Coverage. In this case, there is no evidence to support that the plan issued a recovery notice within 45 days of the plans receipt of complete information regarding the claims adjustment. The documentation shows the date of the recovery notice to the enrollee is January 30, 2023, more than 45 days after the plan's receipt of completed information regarding the claims adjustment on November 14, 2022.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Ilevro prescribed for an unknown diagnosis. 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 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 carefully reviewed the record, the plans formulary and Evidence of Coverage. In this case, there is no evidence to support that the plan issued a recovery notice within 45 days of the plans receipt of complete information regarding the claims adjustment. The documentation shows the date of the recovery notice to the enrollee is January 30, 2023, more than 45 days after the plan's receipt of completed information regarding the claims adjustment on November 14, 2022.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Latanoprost prescribed for an unknown diagnosis. 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 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 carefully reviewed the record, the plans formulary and Evidence of Coverage. In this case, there is no evidence to support that the plan issued a recovery notice within 45 days of the plans receipt of complete information regarding the claims adjustment. The documentation shows the date of the recovery notice to the enrollee is January 30, 2023, more than 45 days after the plan's receipt of completed information regarding the claims adjustment on November 14, 2022.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Ofloxacin prescribed for an unknown diagnosis. 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 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 carefully reviewed the record, the plans formulary and Evidence of Coverage. In this case, there is no evidence to support that the plan issued a recovery notice within 45 days of the plans receipt of complete information regarding the claims adjustment. The documentation shows the date of the recovery notice to the enrollee is January 30, 2023, more than 45 days after the plan's receipt of completed information regarding the claims adjustment on November 14, 2022.