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

At issue is a tiering exception request for Descovy 200/25 milligram tablet prescribed to prevent human immunodeficiency virus (HIV) infection. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.Descovy 200/25 milligram tablet is included in Tier 5 of the plans formulary. Tier 5 of the formulary is the tier reserved for specialty drugs. The specialty tier is exempt from tiered cost-sharing expectations per Medicare rules. Therefore, this drug is not eligible for coverage at a lower-cost tier. A physician reviewer determined that tiering exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Buprenorphine-Naloxone 8-2 milligram sublingual tablet to treat opioid dependence. 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 not that is not on the plans formulary, alternative formulary drugs must have been tried and failed, or deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the formulary alternative drug listed by the plan, Zubsolv sublingual tablet, would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. It should be noted that the formulary alternative drug is a branded version of the requested generic drug. Additionally, the formulary alternative drug is not a sublingual film. It is a sublingual tablet just like the requested drug. 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: Favorable

At issue is Corlanor 5 milligram tablets to treat congestive heart failure. 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.At reconsideration, a diagnosis of inappropriate sinus tachycardia was given. The documentation satisfies the plans coverage criteria. The medical records submitted show the patient has severe orthostatic hypotension because of inappropriate sinus tachycardia upon standing and with increased activity. Additionally, the patient has an intolerance to beta blockers due to the orthostatic hypotension.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 Diclofenac Sodium 3 percent gel to treat radiculopathy lumbar region 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 Otezla 30 milligram tablet prescribed to treat psoriasis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan provided information indicating the enrollee is under a Pharmaceutical Assistance Program (PAP) for the requested drug. Medicare rules state that PAPs operate outside of Medicare Part D. Therefore, we determined the drug is not eligible for coverage or reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Tadalafil 5 milligram tablet. 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.At initial determination, the diagnosis provided by the prescriber for the requested drug was benign prostatic hyperplasia. However, the plan has prior authorization requirements for this drug that must be met before the drug can be approved to treat benign prostatic hyperplasia. The submitted documentation does not support that the plans requirements for coverage of the drug have been met.At redetermination, the diagnosis provided for the requested drug was erectile dysfunction. However, drugs when used for the treatment of sexual or erectile dysfunction are excluded from coverage under Medicare Part D. At reconsideration, the diagnosis for the requested drug has been changed back to benign prostatic hyperplasia. However, no medical records have been submitted to validate which condition is being treated. Furthermore, since no medical records have been submitted, it is not possible to determine if the plans prior authorization requirements for this drug to treat benign prostatic hyperplasia have 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 Mycophenolate Mofetil 500 milligram tablet to treat interstitial pulmonary disease and nonspecific interstitial pneumonia. 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 Oxycodone-Acetaminophen 5/325 milligram tablet to treat lumbar radiculitis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. This drug is on Tier 3 of the plans formulary. The prescriber has not indicated, with the support of medical records, 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: Unfavorable

At issue is Belbuca 300 microgram buccal film to treat chronic pain in an enrollee with long-term use of opiate analgesic. 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 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: Unfavorable

At issue is Celebrex 100 milligram capsule to treat sciatica and degenerative disc disease. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The 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: Unfavorable

At issue is a tiering exception request for Synjardy extended release 25/1000 milligram tablets to treat diabetes. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. This drug 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, it 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 Aimovig 70 milligram per milliliter auto-injector. 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 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

Omega-3-Acid Ethyl Esters 1 gram capsule was requested to treat the enrollees condition. The case was auto-forwarded by the planWe 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 Aranesp (Albumin free) 500 microgram per milliliter solution prefilled syringe to treat anemia in chronic kidney disease. 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.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed or were contraindicated. However, we did not receive the requested information.The requested 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: Unfavorable

At issue is Jardiance 25 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request. We received a 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 for part of the cost for this drug and entered the coverage gap stage for the remaining amount. The plans Evidence of Coverage states, reimbursement is calculated based on the total cost, minus the required copayment or coinsurance amount, and minus the difference between what the plan normally pays for the tier 3 drug and what the pharmacy charged the enrollee while in the initial coverage stage. During the coverage gap stage the enrollee pays 25 percent of the price for brand name drugs. The plan provided documentation showing the approved amount for the requested drug was $2025.65. The enrollees cost share was calculated based on a $131.00 copay in the initial coverage stage, and 25 percent of the remaining amount of $1802.92, which is $450.73 in the coverage gap stage. Therefore, the enrollee's copayment of $581.73 was calculated correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix 50 microgram/0.5 milliliter suspension prescribed for vaccination. The Part D plan auto-forwarded 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 vaccine was administered in the prescriber's office. The plans Evidence of Coverage states that enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined the amount the enrollee paid was applied to the deductible and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 20.25 milligram per 1.25 gram (1.62 percent) transdermal gel pump to treat testicular hypofunction. 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 requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Droxidopa 100 milligram capsules to treat orthostatic hypotension. 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 submitted documentation supports the Part D plan has approved a prior authorization for this drug starting July 01, 2022, through October 29, 2022. The appellant requested a tiering exception for the drug. This drug is being provided by the plan at the cost sharing level of the Specialty tier. The plan's Explanation of Coverage (EOC) indicates that Specialty tier drugs are not available for a tiering exception. A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synvisc One injection solution. 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. Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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. The drug at issue does not meet the definition of a Part D drug as it has been classified as a device.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Victoza 18 milligram per 3 milliliter pen injector to treat type 2 diabetes mellitus with diabetic neuropathy, unspecified. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records to support 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: Favorable

At issue is Simponi 50 milligram per 0.5 milliliter injection solution to treat ankylosing spondylitis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The documentation satisfies the plans coverage criteria. The submitted documentation indicates the enrollee has a diagnosis of ankylosing spondylitis. The Medicare approved compendia contain citations to support the use of the drug for this diagnosis. Therefore, the drug was prescribed for a medically accepted indication. Furthermore, the documentation supports the enrollee has tried and failed therapy with Humira and Enbrel. 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 a tiering exception request for Nexletol 180 milligram tablet to treat chronic ischemic heart disease and mixed hyperlipidemia. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cosentyx 150 milligram per milliliter solution pen auto-injector to treat hidradenitis suppurativa. 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 Nurtec 75 milligram oral disintegrating tablet to treat migraine headaches. 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 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: Unfavorable

At issue is Kapspargo Sprinkle 100 milligram extended release oral capsule to treat an unknown diagnosis. The Part D plan auto-forwarded the request. We received the submitted documentation to perform an independent and de novo review. 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. The prescriber was asked to provide a diagnosis and wrote, 'N/A.' A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.