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

At issue is Atovaquone 750 milligram per 5 milliliter oral suspension prescribed as prophylaxis against Pneumocystis jurovecii infection in an immunosuppressed enrollee being treated for pemphigus foliaceous. 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 is not eligible for coverage under Medicare Part D. This decision does not speak to the medical necessity of this drug; it speaks to whether the Part D drug plan is responsible for payment under CMS rules. 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 Aranesp 500 microgram per milliliter syringe to treat anemia related to chronic kidney disease without dialysis. 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 Mybetriq extended release 50 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, including the case file from the plan, and any information submitted at the reconsideration level.Mybetriq extended release 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 FlowFlex COVID-19 Test. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The requested test kit is considered a non-prescription product and does not meet the definition of a Part D drug. Therefore, the requested product is excluded from coverage under the Part D benefit and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acetaminophen 325 milligram tablet. 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 plan submitted documentation showing the enrollee received Acetaminophen as a self-administered drug in an outpatient hospital stay. According to the plan's Evidence of Coverage, if the 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 based on the enrollee's cost share stage and out-of-network (hospital). The documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. In addition, the statement indicates that a discount was provided, but did not provide a breakdown of the applied discount to each drug. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alprazolam 0.5 milligram tablet. 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 plan submitted documentation showing the enrollee received Alprazolam as a self-administered drug in an outpatient hospital stay. According to the plan's Evidence of Coverage, if the 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 based on the enrollee's cost share stage and out-of-network (hospital). The documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. In addition, the statement indicates that a discount was provided, but did not provide a breakdown of the applied discount to each drug. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bupropion extended release 24 hour 150 milligram tablet. 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 plan submitted documentation showing the enrollee received Bupropion as a self-administered drug in an outpatient hospital stay. According to the plan's Evidence of Coverage, if the 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 based on the enrollee's cost share stage and out-of-network (hospital). The documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. In addition, the statement indicates that a discount was provided, but did not provide a breakdown of the applied discount to each drug. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ezetimibe 10 milligram tablet. 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 plan submitted documentation showing the enrollee received Ezetimibe as a self-administered drug in an outpatient hospital stay. According to the plan's Evidence of Coverage, if the 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 based on the enrollee's cost share stage and out-of-network (hospital). The documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. In addition, the statement indicates that a discount was provided, but did not provide a breakdown of the applied discount to each drug. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Famotidine 20 milligram tablet. 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 plan submitted documentation showing the enrollee received Famotidine as a self-administered drug in an outpatient hospital stay. According to the plan's Evidence of Coverage, if the 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 based on the enrollee's cost share stage and out-of-network (hospital). The documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. In addition, the statement indicates that a discount was provided, but did not provide a breakdown of the applied discount to each drug. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Guanfacine 1 milligram tablet. 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 plan submitted documentation showing the enrollee received Guanfacine as a self-administered drug in an outpatient hospital stay. According to the plan's Evidence of Coverage, if the 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 based on the enrollee's cost share stage and out-of-network (hospital). The documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. In addition, the statement indicates that a discount was provided, but did not provide a breakdown of the applied discount to each drug. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydralazine 25 milligram tablet. 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 plan submitted documentation showing the enrollee received Hydralazine as a self-administered drug in an outpatient hospital stay. According to the plan's Evidence of Coverage, if the 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 based on the enrollee's cost share stage and out-of-network (hospital). The documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. In addition, the statement indicates that a discount was provided, but did not provide a breakdown of the applied discount to each drug. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydralazine 50 milligram tablet. 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 plan submitted documentation showing the enrollee received Hydralazine as a self-administered drug in an outpatient hospital stay. According to the plan's Evidence of Coverage, if the 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 based on the enrollee's cost share stage and out-of-network (hospital). The documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. In addition, the statement indicates that a discount was provided, but did not provide a breakdown of the applied discount to each drug. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levothyroxine 75 microgram tablet. 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 plan submitted documentation showing the enrollee received Levothyroxine as a self-administered drug in an outpatient hospital stay. According to the plan's Evidence of Coverage, if the 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 based on the enrollee's cost share stage and out-of-network (hospital). The documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. In addition, the statement indicates that a discount was provided, but did not provide a breakdown of the applied discount to each drug. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Losartan 100 milligram tablet. 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 plan submitted documentation showing the enrollee received Losartan as a self-administered drug in an outpatient hospital stay. According to the plan's Evidence of Coverage, if the 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 based on the enrollee's cost share stage and out-of-network (hospital). The documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. In addition, the statement indicates that a discount was provided, but did not provide a breakdown of the applied discount to each drug. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pantoprazole 40 milligram tablet. 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 plan submitted documentation showing the enrollee received Pantoprazole as a self-administered drug in an outpatient hospital stay. According to the plan's Evidence of Coverage, if the 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 based on the enrollee's cost share stage and out-of-network (hospital). The documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. In addition, the statement indicates that a discount was provided, but did not provide a breakdown of the applied discount to each drug. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Polyethylene Glycol 17 gram powder pack. 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 plan submitted documentation showing the enrollee received Polyethylene Glycol as a self-administered drug in an outpatient hospital stay. According to the plan's Evidence of Coverage, if the 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 based on the enrollee's cost share stage and out-of-network (hospital). The documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. In addition, the statement indicates that a discount was provided, but did not provide a breakdown of the applied discount to each drug. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Saccharomyces Boulardii 250 milligram capsule. 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 plan submitted documentation showing the enrollee received Saccharomyces Boulardii as a self-administered drug in an outpatient hospital stay. According to the plan's Evidence of Coverage, if the 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 based on the enrollee's cost share stage and out-of-network (hospital). The documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. In addition, the statement indicates that a discount was provided, but did not provide a breakdown of the applied discount to each drug. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sennosides Docusate Sodium 8.6-50 milligram tablet. 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 plan submitted documentation showing the enrollee received Sennosides Docusate Sodium as a self-administered drug in an outpatient hospital stay. According to the plan's Evidence of Coverage, if the 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 based on the enrollee's cost share stage and out-of-network (hospital). The documentation includes a hospital statement showing the amount charged for the self-administered drug and a payment receipt. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. In addition, the statement indicates that a discount was provided, but did not provide a breakdown of the applied discount to each drug. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Partially Favorable

At issue is Nurtec 75 milligram disintegrating tablet, 24 tablets per 24 days, to treat acute migraine headache. 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 prior authorization criteria. The prescriber provided medical records from date of service 7/5/2022.  The medical records document that the requested drug is being used for the treatment of acute migraine headache in an adult enrollee.  The enrollee has experienced an inadequate treatment response to Imitrex.  However, the plan's quantity limit is 16 tablets per 30 days.  The prescriber is requesting 24 tablets per 24 days, which exceeds the amount allowed by the plan.  The product label, available at drugs@fda, states:  The safety of using more than 18 doses in a 30-day period has not been established.  Therefore, an exception to the plans quantity limit criteria is not supported. A physician reviewed the appeal and determined that the requested drug, Nurtec 75 milligram disintegrating tablet is eligible for Part D coverage at the plan's quantity limit.  However, an exception to the plan's quantity limit can not be made.
Appeal type: Prescription Drug
Decision: Unfavorable

Prolensa 0.07 percent drops was requested to treat the enrollees condition. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.A request was submitted to the prescriber to provide a diagnosis, the nonformulary exception 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.