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

At issue is coverage for Edarbi 80 milligram tablet to treat essential (primary) hypertension. 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.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that all formulary alternatives were tried and failed or were deemed contraindicated. We received additional documentation and included it in the review. 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 Cefpodoxime 200 milligram tablet prescribed on 12/11/2023 for unknown diagnosis. The Part D plan denied the reimbursement 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 enrollee submitted documentation indicating the requested drug was purchased at a network pharmacy with a tier 4 copay. The enrollee indicates the drug was filled for the 100-milligram dose with a lower copay and asking the plan to consider the drug as a tier 2 exception. The drug is available in 100 milligram tablets on tier 2 of the plan's formulary. The drug was not tried and failed, as drug was still being used in a 200-milligram dose. Reimbursement for tier exception copay was not proven. In addition, the submitted documentation shows the enrollee requested the Part D plan to provide reimbursement for the copay of the requested drug purchased from a network pharmacy. In addition, there is missing information needed to consider the request. The required information includes the National Drug Code (NDC) of the requested drug and the prescribing physicians name, address and National Provider Identifier (NPI) number, and paid receipt by the enrollee. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tenivac intramuscular injectable 5-2 LF Units vaccine and administration fee 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 available documentation.The submitted documentation indicates the vaccine was obtained and administered in the physicians office. The appeal submitted by the enrollee is for an amount of $125.00. The enrollee submitted a Reimbursement Form indicating the type of reimbursement for is a tetanus/diphtheria vaccine in the amount of $58.00. The documentation also includes a Physician Services Bill Summary from Sutter Medical Foundation dated September 28, 2023, for $58.00, for Procedure/Monitoring performed on December 19, 2022. Furthermore, there is a receipt showing the enrollee paid $58.00 through SMF online bill pay. However, the bill does not indicate what service was rendered to the enrollee on that date. Additionally, there is no information submitted concerning the additional monies to be reimbursement by the enrollee. Without a properly itemized bill and receipt for all services, the plan is not required to reimburse the enrollee.
Appeal type: Prescription Drug
Decision: Favorable

At issue is reimbursement for a Shingrix vaccine received on April 14, 2021. 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 providers itemized bill gives a valid National Drug Code for a Shingrix vaccine and supports the vaccine was administered in the providers office on April 14, 2021, for the amount of $220.00. The drug is on the plans formulary and the plan indicates they confirmed with the providers office that the enrollee has paid the amount by a credit card over the phone. The documentation is sufficient to support reimbursement for the shingle vaccine. Therefore, we determined that the plan is required to reimburse the enrollee for their share of the cost for the Shingrix vaccine for the date of service April 14, 2021.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Hydrocodone/Acetaminophen 5/325 milligram tablet to treat low back pain. The Part D plan denied the request for additional reimbursement.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The plan submitted documentation that shows the enrollee paid full price for the Hydrocodone/Acetaminophen at a net-work pharmacy. 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. We determined that the plan calculated reimbursement correctly and is not required to offer additional reimbursement. Please note, this reconsideration decision was based on the plans 2023 coverage criteria.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluorouracil 5 percent compounded drug prescribed to treat planta warts. 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. This includes the case file from the plan, and any information submitted at the reconsideration level.Drugs that fall into the category of bulk powders/compounds do not meet the definition of a Part D drug. The requested drug is considered a bulk powder/compound consistent of ingredients and is excluded from coverage under Part D. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Celexa 40 milligram tablet. 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 provided claim information for the enrollee indicating the drug at issue was dispensed at a pharmacy not in the plans network on the dates the prescription was filled. In these instances, the enrollee may be responsible for paying the difference between what he/she pays for the drug at the out of network pharmacy and the cost that the plan would cover at an in network pharmacy. The documentation does not support an extreme emergency that would require the drug be immediately supplied and the drug could have been received from a network pharmacy. Therefore, we determined that the plan is not required to provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Dupixent 300 milligrams per 2 milliliters solution pen injector to treat atopic dermatitis, unspecified. 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 validate 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 10 milligram tablet to treat muscle spasms. 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 Ubrelvy 100 milligram tablet to treat chronic migraine headaches. 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 Rytary 36.25 milligram/145 milligram extended release capsule 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 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 Eliquis 5 milligram tablet for the prophylaxis of pulmonary embolism. 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.Eliquis 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 Prosol 20 percent injection to treat end stage renal disease and protein-calorie malnutrition. 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 Savella 50 milligram tablet to treat fibromyalgia. 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 reimbursement for Hydralazine Hydrochloride 25 milligram tablet for unknown diagnosis. 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 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 record shows the enrollee received a 10 day supply of the requested drug on December 1, 2023. The pharmacy tried to run another 10 day supply on December 6, 2023, which was one day before the eligible fill date and was rejected. On December 11, 2023, the enrollee filled a 90 day supply. According to the plans Evidence of Coverage, limits and restrictions are placed on drugs that are refilled too soon. Therefore, the claim for fill date December 6, 2023, for $11.99, was rejected at point of sale for refill too soon, and the amount charged to the enrollee was an out-of-pocket expense. We determined no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Erleada 60 milligram tablet to treat prostate cancer. 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.Erleada is included on 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 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 Xtandi 40 milligram tablet to treat prostate cancer. 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.Xtandi is included on 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 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 Ozempic 1 milligram per dose solution pen-injector (4 milligram per 3 milliliters) to treat obesity and pre diabetes. 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 Welireg 40 milligram tablet to treat metastatic renal cell carcinoma, as first-line treatment. 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 compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. The submitted documentation does not include any clinically relevant, peer-reviewed medical literature from a Medicare approved journal to support this appeal. Therefore, the available documentation supports that the requested drug is not being prescribed for a medically accepted indication, as defined by Medicare.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 Amphetamine Dextroamphetamine 5 milligram tablet prescribed 3 times daily. 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 submitted documentation does not include medical records or evidence of a prescribed diagnosis. This information was requested by the Part D plan with no response from the prescriber regarding a diagnosis or medical records. The documentation submitted at reconsideration also does not include medical records or evidence of a prescribed diagnosis. As such, there is insufficient documentation available to establish that the requested drug has been prescribed for a medically accepted indication.The plans quantity limit for the requested drug is 60 tablets per 30 days. The prescriber has not provided patient-specific clinical rationale as to why the amount allowed by the plan would be ineffective in treating the diagnosis and/or would be contraindicated. Furthermore, the submitted documentation does not support the medical necessity for an exception to the plans quantity limit for the drug. 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 Enbrel Sureclick 50 milligram per milliliter to treat rheumatoid arthritis. 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, reviewed all available documentation.The submitted documentation indicates that the enrollee is currently enrolled in a Patient Assistance Program (PAP) for the purchases of the requested drug for the coverage year 2023. Medicare rules state that PAPs operate outside of Medicare Part D. Therefore, the drug is not eligible for coverage under the Part D benefit.This decision does not address the medical necessity of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Pradaxa 110 milligram capsule. 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.Pradaxa 110 milligram capsule is a brand drug on Tier 3of the plans formulary. There are no brand rugs 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 Nurtec ODT (oral disintegrating tablet) 75 milligrams, 9 tablets per 9 days, to treat migraine headaches. 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 plans quantity limit for the requested drug is 16 tablets per 30 days. The prescriber has not provided patient-specific clinical rationale as to why the amount allowed by the plan would be ineffective in treating the diagnosis and/or would be contraindicated. Furthermore, the submitted documentation does not support the medical necessity for an exception to the plans quantity limit for the drug. The following citation referenced in Drugdex, a Medicare approved compendium states, 'The safety of using more than 18 doses per 30 days has not been established [1]. [1] Product Information: NURTEC(R) ODT orally disintegrating tablets, Rimegepant orally disintegrating tablets. Biohaven Pharmaceuticals Inc (per FDA), New Haven, CT, 2021.'A physician reviewed the appeal and determined that the requested drug at the requested amount is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Zolpidem Tartrate ER (extended release) 12.5 milligram tablet to treat insomnia. 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 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.