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

At issue is Hydrocodone Acetaminophen 5-325 milligram tablet for diagnosis not provided. 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 submitted documentation shows the enrollee was given the requested drug while in a hospital outpatient stay. Self-administered drugs are processed as out-of-network benefits and reimbursement is based on the difference in what the hospital/out-of-network pharmacy charges and what the plan allows, minus the enrollee's deductible, copayment or coinsurance. We determined the amount paid for this drug was applied to the deductible and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent patch quantity 1 for diagnosis not provided. 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 submitted documentation shows the enrollee was given the requested drug while in a hospital outpatient stay. Self-administered drugs are processed as out-of-network benefits and reimbursement is based on the difference in what the hospital/out-of-network pharmacy charges and what the plan allows, minus the enrollee's deductible, copayment or coinsurance. We determined the amount paid for this drug was applied to the deductible and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent patch quantity 14 for diagnosis not provided. 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 submitted documentation shows the enrollee was given the requested drug while in a hospital outpatient stay. Self-administered drugs are processed as out-of-network benefits and reimbursement is based on the difference in what the hospital/out-of-network pharmacy charges and what the plan allows, minus the enrollee's deductible, copayment or coinsurance. We determined the amount paid for this drug was applied to the deductible and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxcodone Acetaminophen 5-325 milligram tablet for diagnosis not provided. 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 submitted documentation shows the enrollee was given the requested drug while in a hospital outpatient stay on October 31, 2021. Self-administered drugs are processed as out-of-network benefits and reimbursement is based on the difference in what the hospital/out-of-network pharmacy charges and what the plan allows, minus the enrollee's deductible, copayment or coinsurance. We determined the amount paid for this drug was applied to the deductible and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone Acetaminophen 5-325 milligram tablet for diagnosis not provided. 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 submitted documentation shows the enrollee was given the requested drug while in a hospital outpatient stay on October 25, 2021. Self-administered drugs are processed as out-of-network benefits and reimbursement is based on the difference in what the hospital/out-of-network pharmacy charges and what the plan allows, minus the enrollee's deductible, copayment or coinsurance. We determined the amount paid for this drug was applied to the deductible and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Januvia 100 milligram tablets to treat type II diabetes mellitus with hyperglycemia. 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.Januvia 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 reimbursement request for Aprepitant 40 milligram capsules. 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 record shows the enrollee received the drug at issue in the hospital. The enrollee submitted a valid National Drug Code for the drug at issue. However, 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 Eliquis 5 milligram tablets (60 tablets per 30 days) for prophylaxis of cerebral vascular accident and systemic embolism related to atrial fibrillation. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan limits the amount of Eliquis to 74 tablets per 30 days. The requested quantity is within the plans allowed quantity limit. 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 Oxazepam 15 milligram capsules. 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

At issue is a tiering exception request for Myrbetriq ER (Extended-Release) 25 milligram tablets to treat urge incontinence. 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.Myrbetriq ER is a brand drug on Tier 4 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 coverage for Freestyle Libre 2 reader and sensors for a continuous glucose monitoring system prescribed for the monitoring of type 2 diabetes mellitus. The Part D plan 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.Medicare classifies continuous glucose monitoring systems as durable medical equipment. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment. Additionally, Medicare Part B pays for the supplies necessary for the effective use of durable medical equipment, such as supplies for a continuous glucose monitoring system. Coverage under Part D is excluded for any item for which payment would be available under Part B. As such, coverage for the Freestyle Libre 2 reader and sensors is not eligible through Medicare Part D.This decision does not address the medical necessity or appropriateness of the item. It only establishes that payment cannot be made under the Medicare Part D benefit. It has been noted by the Part D plan that coverage for the requested items has already been approved under the enrollees Medicare Part B benefit from 04/13/2022 until further notice under authorization number PA-13288085. Please submit claims for these items through Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Rasagiline Mesylate 1-milligram tablet to treat Parkinsons 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 documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug that must be met before coverage can be approved. The submitted documentation does not support that all of the plans requirements for coverage 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 coverage for Xeljanz 5-milligram tablet to treat alopecia areata universalis. 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 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 Auryxia 210-milligram ferric iron tablet, equivalent to 1-gram ferric citrate, prescribed to treat iron-deficiency anemia associated with chronic kidney 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 documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.Auryxia is a mineral product. Prescription vitamin and mineral products are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Sodium Citrate-Citric Acid 500-334-milligram per 5-milliliter oral solution to treat acidosis. 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 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.Sodium Citrate-Citric Acid oral solution has not been found by the Food and Drug Administration (FDA) to be safe and effective, and the drug product labeling has not been approved by the FDA. A drug that has not been approved by the FDA does not meet the definition of a Part D drug. As such, the requested drug is excluded from Part D coverage.This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Zarxio 300-microgram per 0.5-milliliter prefilled injection syringe. The Part D plan denied the request for coverage because the prior authorization requirements were not met due to the provided diagnosis. 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 diagnosis initially provided to the plan for the requested drug was neutropenia, unspecified. The prescriber statement and medical records submitted at reconsideration clarify that the enrollee is being treated for drug-induced neutropenia, specifically, the myelosuppressive drug, Valganciclovir. The prescriber explains that the enrollee underwent a double lung transplant and contracted cytomegalovirus (CMV) from the donor. The enrollee, who was already immunocompromised due to transplant rejection therapy, then developed CMV viremia that required treatment with Valganciclovir, which in cause resulted in the enrollee developing neutropenia. The Medicare approved compendium, American Hospital Formulary Service Drug Information (AHFS-DI), includes a citation that notes, Filgrastim (Zarxio) has been used effectively in a limited number of patients with nonmalignant conditions who developed neutropenia while receiving various myelosuppressive drugs. As Valganciclovir is a myelosuppressive drug, the documentation supports that the requested drug is being used for a medically accepted indication as outlined in the Medicare approved compendium, AHFS-DI. The plans prior authorization requirements for the drug are diagnosis specific and do not relate to the condition being treated. Since the drug is being used for a medically accepted indication as outlined in AHFS-DI, an exception to the plans diagnosis-specific coverage requirements is supported. The plan has no quantity limit or step therapy requirements for the drug. As such, the documentation submitted at reconsideration supports coverage for the drug.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 Ozempic 2-milligrams/1.5-milliliter injection to treat weight loss. 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 chronic progressive prediabetes was given. No documentation was provided by the prescriber. 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. Additionally, drugs prescribed to treat weight loss (promote weight gain) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Meloxicam 15-milligram tablet, 60 tablets per 30 days, to treat arthritis pain. The Part D plan denied the request for 60 tablets per 30-day supply. 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 amount of Meloxicam 15-milligram tablets requested, 60 tablets per 30 days, exceeds the plans quantity limit for the drug of 30 tablets per 30 days. The submitted documentation does not support an exception to the plans quantity limit for the requested drug.A physician reviewed the appeal and determined that the plan is not required to cover more than 30 tablets per 30-day supply of the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 5-milligram capsule to treat nausea and vomiting due to cervicocranial syndrome. 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, diagnoses of post-chemotherapy, post-stroke, and vertigo were given. The use of the requested drug to treat the provided diagnosis are off-label uses. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these diagnoses. 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 Albuterol solution prescribed for pneumonia due to COVID-19. The Part D plan denied 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 requested the Part D plan to provide reimbursement for the requested drug purchased during an emergency room visit. However, there is missing information needed to consider the request. The required information includes the dosage, quantity and National Drug Code (NDC) of the requested drug, and the prescribing physicians name, address and National Provider Identifier (NPI) number. Therefore, reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nimodipine 30 milligram capsule prescribed for diagnosis not provided. The Part D plan denied 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 indicates the claim for the requested drug was approved and the appropriate amount was charged to the enrollee at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment or coinsurance amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. We determined no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Synthroid 150-microgram tablet. 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.Synthroid is a brand drug on Tier 4 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 Lidocaine 5-percent patch to treat pelvic pain and arthritis. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The 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 Fluticasone Propionate 50-microgram nasal spray 16-gram for 15-day supply to treat allergic rhinitis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The plan has a limit on Fluticasone Propionate 50-microgram nasal spray of 0.54-gram per day. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the diagnosis or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Norethindrone Acetate-Ethinyl Estradiol 1-milligram/5-microgram tablet to treat vasomotor symptoms due to menopause. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Dilantin 100-microgram capsule to treat localization-related idiopathic epilepsy and epileptic syndromes with seizures of localized onset. 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.Dilantin is a brand drug on Tier 4 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.