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

At issue is coverage for Acitretin 17.5 milligram capsule to treat ichthyosis. 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 available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. 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 drug is being prescribed for a non-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 Atorvastatin 20 milligram tablet prescribed for unknown 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.Of note, Atorvastatin filled on 8/11/2022 and 9/23/2022 which you are seeking reimbursement, were previously processed by another insurance provider. Previously submitted processed claims cannot be reimbursed. We determined no further reimbursement is required by plan.The plan submitted documentation that shows the enrollee was in the initial coverage stage of the Part D benefit when this drug was purchased. According to the plans Evidence of Coverage, the amount paid for the formulary tier 2 drug at a network pharmacy on 11/29/2022 and 12/03/2022 were less than the copay. The record shows the full price of the drug was less than the $20 copay amount. Therefore, the enrollees charge was based on the total cost of the drug. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gabapentin 100 milligram capsule prescribed for unknown 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 in the initial coverage stage of the Part D benefit when this drug was purchased. According to the plans Evidence of Coverage, the amount paid for the formulary tier 2 drug at a network pharmacy on 8/22/2022 and 12/02/2022 were less than the copay. The record shows the full price of the drug was less than the $20 copay amount. Therefore, the enrollees charge was based on the total cost of the drug. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levothyroxine 50 microgram tablet prescribed for unknown 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.Of note, Levothyroxine filled on 8/11/2022 and 9/23/2022 which you are seeking reimbursement, were previously processed by another insurance provider. Previously submitted processed claims cannot be reimbursed. We determined no further reimbursement is required by plan.The plan submitted documentation that shows the enrollee was in the initial coverage stage of the Part D benefit when this drug was purchased. According to the plans Evidence of Coverage, the amount paid for the formulary tier 1 drug at a network pharmacy on 11/29/2022 and 12/03/2022 were less than the copay. The record shows the full price of the drug was less than the $20 copay amount. Therefore, the enrollees charge was based on the total cost of the drug. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prednisolone Acetate 1 percent suspension submitted for the dates of 10/6/2022 and 11/10/2022 for 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. This includes the case file from the plan, and any information submitted at the reconsideration level.Of note, Prednisolone Acetate 1 percent suspension filled on 8/11/2022 and 9/23/2022 which you are seeking reimbursement, were previously processed by another insurance provider. Previously submitted processed claims cannot be reimbursed. We determined no further reimbursement is required by plan.The plan submitted documentation that shows the enrollee was in the deductible stage for part of the cost for the drug and entered the initial coverage stage for the remaining amount. The claim information provided indicates $67.58 of the cost was applied to the enrollee's deductible of 480.00 dollars. Because the deductible had not yet been met, the $67.58 for Prednisolone Acetate1 precent suspension went toward the deductible. 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 Trazadone 100 milligram tablet prescribed for unknown 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.Of note, Trazodone filled on 8/11/2022 and 9/23/2022 which you are seeking reimbursement, were previously processed by another insurance provider. Previously submitted processed claims cannot be reimbursed. We determined no further reimbursement is required by plan.The plan submitted documentation that shows the enrollee was in the initial coverage stage of the Part D benefit when this drug was purchased. According to the plans Evidence of Coverage, the amount paid for the tier 2 drug at a network pharmacy on 8/22/2022 and 12/02/2022 were less than the copay. The record shows the full price of the drug was less than the $20 copay amount. Therefore, the enrollees charge was based on the total cost of the drug. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Atorvastatin 40 milligram tablets. 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 2023 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 claim information shows the cost of the drug was more than the plan approved amount. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Rinvoq 15 milligram extended release tablet to treat pruritus. 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 available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. 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 drug is being prescribed for a non-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 coverage for Neupro 4 milligram per 24 hour patch to treat Parkinson's disease. 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 available documentation.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 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 support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements 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 coverage for Breo Ellipta 300 microgram/25 microgram per actuation. 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 available documentation.The record shows the plan reprocessed claims for the Breo Ellipta and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Prednisone 10 milligram tablet. 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 available documentation.The record shows the plan reprocessed claims for the Prednisone and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Ventolin HFA (Hydrofluoroalkane) 90 microgram per actuation. 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 available documentation.The record shows the plan reprocessed claims for the Ventolin HFA and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Shingrix vaccine prescribed for the enrollee's condition. 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 received the vaccine at the prescriber's office for immunization purposes. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or prescribers office. 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 enrollee provided proof of payment in the form of a receipt. Therefore, the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Procardia 30 milligram extended release tablet to treat essential hypertension. 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 available documentation. 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 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 support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements 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 a tiering exception request for Alphagan P 0.1 percent drops 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 available documentation. Alphagan P 0.1 percent drops is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Saxenda 3 milligram per 0.5 milliliter pen injector to treat obesity. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Drugs prescribed to treat obesity and/or to promote weight loss are excluded from the Part D coverage. Therefore, the requested drug is excluded from Medicare Part D coverage.This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Oxycontin 30 milligram ER (extended release) 12-hour tablet to treat chronic pain with around the clock opioid analgesic. 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 available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. 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 coverage for Cyclobenzaprine Hydrochloride 5 milligram tablets to treat ankylosing spondylitis of multiple sites in the spine. 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 available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. 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 drug is being prescribed for a non-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 coverage for Januvia 25 milligram tablet prescribed for the enrollee's condition. The Part D plan denied the request for additional reimbursement. We received a 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 plan submitted documentation that shows the enrollee was in the initial coverage stage for part of the cost for this drug and entered the coverage gap stage for the remaining amount. According to the plans Evidence of Coverage, reimbursement is calculated based on the total cost of the drug, minus the required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged the enrollee while in the initial coverage stage. During the coverage gap stage the enrollee pays 25% of the price for brand name drugs and a portion of the dispensing fee. The record shows the plan paid its share of the cost for the Januvia, and the enrollees cost share was calculated based on a portion of copay in the initial coverage stage and 25% of the coverage gap discount for the remaining amount. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Sodium Bicarbonate 650 milligram tablet to treat kidney failure and cirrhosis of liver. 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 available documentation.Sodium Bicarbonate 650 milligram tablet is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Fluticasone/Salmeterol 230 microgram/21 microgram per actuation inhalation aerosol liquid to treat mild persistent asthma with acute exacerbation. 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 available documentation.Fluticasone/Salmeterol is a generic drug on Tier 3 of the plans formulary. There are no generic drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Wegovy 1 milligram per 0.5 milliliter auto injector to promote weight loss. 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 available documentation.Drugs prescribed to treat obesity and/or to promote weight loss are excluded from the Part D coverage. Therefore, the requested drug is excluded from Medicare Part D coverage.This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Mounjaro 2.5 milligrams per 0.50 milliliter subcutaneous solution to treat type 2 diabetes mellitus. 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 available documentation. 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 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 support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements 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: Favorable

At issue is coverage for Modafinil 200 milligram tablet, 30 tablets per 30 days, to treat multiple sclerosis-related fatigue. 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 available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The Medicare approved compendium, Drugdex, includes an off-label indication for the use of the requested drug to treat fatigue associated with multiple sclerosis. Therefore, the requested drug is being prescribed to treat a medically accepted indication.The plan has prior authorization requirements that must be met before coverage of this drug is provided. However, the plans prior authorization requirements are diagnosis-specific and not related to the condition being treated. Since the condition being treated is a medically accepted indication outlined in Drugdex, an exception to the plans diagnosis-specific coverage requirements is supported. 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 Aimovig solution auto-injector to treat chronic migraines. 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 available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. 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.