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

At issue is Freestyle LIbre 14 day sensors prescribed for the enrollee's condition. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Supplies for testing and monitoring blood glucose levels are not considered Part D drugs and may be covered under the Medicare Part B durable medical equipment benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 25 milligram tablet prescribed for the enrollee's condition. 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. Medicare records show the enrollee was not enrolled with the Part D plan for the dates of service requested. Therefore, we determined that the plan is not required to provide coverage or reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lisinopril 5 milligram tablet prescribed for the enrollee's condition. 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. Medicare records show the enrollee was not enrolled with the Part D plan for the dates of service requested. Therefore, we determined that the plan is not required to provide coverage or reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic 0.25/0.5 milligram solution pen injector prescribed for the enrollee's condition. 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. Medicare records show the enrollee was not enrolled with the Part D plan for the dates of service requested. Therefore, we determined that the plan is not required to provide coverage or reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic 2 milligram per milliliter solution pen injector prescribed for the enrollee's condition. 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. Medicare records show the enrollee was not enrolled with the Part D plan for the dates of service requested. Therefore, we determined that the plan is not required to provide coverage or reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Trulicity 3 milligram per 0.5 milliliter subcutaneous injection pen purchased on August 6, 2022. The Part D plan denied the request and then auto-forwarded the request to us for review.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 requested drug was purchased. The plans Evidence of Coverage states that the enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined this drug was paid correctly and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Amitriptyline 50 milligram tablet. The case was auto-forwarded by the plan.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 plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. The record shows the amount in question is the total of the co-payment for the drug at issue. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested compounded drug Oleabase plasticized ointment to treat the enrollees condition. The Part D plan denied your request.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 plan denied your request for reimbursement because the compound powder does not meet the definition of a Part D drug. The National Drug Code verified with the Food and Drug Administration, is not valid. Therefore, the compound powder is not eligible for coverage under Medicare Part D. We determined the plan is not required to provide reimbursement for the Oleabase plasticized ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested compounded drug Tetracaine powder to treat the enrollees condition. The Part D plan denied your request.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 plan denied your request for reimbursement because the compound powder does not meet the definition of a Part D drug. The National Drug Code verified with the Food and Drug Administration, is not valid. Therefore, the compound powder is not eligible for coverage under Medicare Part D. We determined the plan is not required to provide reimbursement for the Tetracaine powder.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Enstilar 0.005-0.064 percent foam to treat seborrheic dermatitis. 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 Aptiom 400 milligram tablet to treat seizure disorder. 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 at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62 percent gel to treat low testosterone. 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: Favorable

At issue is a tiering exception request for Estring 2 milligram to treat vaginal atrophy. 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.Estring 2 milligram is a brand drug on Tier 4 of the plans formulary. The prescriber has stated that all lower tiered drugs to treat the diagnosis have been tried and failed or provided reasons why they would likely not be as effective as the requested drug. Therefore, this drug is eligible for an exception.A physician reviewer determined that tiering exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rayaldee 30 microgram extended release capsule to treat secondary hyperparathyroidism, chronic kidney 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 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 Jardiance 25 milligram tablet to treat your condition. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Jardiance 25 milligram tablet 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 Cimzia 2 X 200 milligram per milliliter syringe kit to treat rheumatoid 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 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 Zioptan 0.0015 percent drops (90 blister packs per 30 days) to treat ocular hypertension. 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 limits the amount of Zioptan 0.0015 percent drops to 30 blister packs per 30 days. 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

We have dismissed your drug benefit request for Amlodipine 5 milligram tablets because our records show your request does not have a coverage determination by the plan. You must first submit your drug benefit request to the plan; if they review your case and make an unfavorable or a partially favorable decision, you may then have appeal rights to file a request for a redetermination (first level of appeal). You may file a request for reconsideration after the plan issues an unfavorable or partially favorable decision to:United States Postal Service (USPS)C2C Innovative Solutions, Inc.Part D Drug ReconsiderationsP.O. Box 44166Jacksonville, FL 32231-4166UPS / FedEx OnlyC2C Innovative Solutions, Inc.Part D QIC301 W. Bay St., Suite 600Jacksonville, FL 32202
Appeal type: Prescription Drug
Decision: Unfavorable

We have dismissed your drug benefit request for Irbesartan because our records show your request does not have a coverage determination by the plan. You must first submit your drug benefit request to the plan; if they review your case and make an unfavorable or a partially favorable decision, you may then have appeal rights to file a request for a redetermination (first level of appeal). You may file a request for reconsideration after the plan issues an unfavorable or partially favorable decision to:United States Postal Service (USPS)C2C Innovative Solutions, Inc.Part D Drug ReconsiderationsP.O. Box 44166Jacksonville, FL 32231-4166UPS / FedEx OnlyC2C Innovative Solutions, Inc.Part D QIC301 W. Bay St., Suite 600Jacksonville, FL 32202
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Pantoprazole Sodium 40 milligram tablet to treat your condition. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Pantoprazole Sodium 40 milligram tablet is a brand drug on Tier 1 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 tiering exception request for Trelegy Ellipta 100 microgram-62.5 microgram-25 microgram aerosol to treat asthma and chronic obstructive pulmonary 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.Trelegy Ellipta 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 Pregabalin 25 milligram capsule to treat bilateral occipital neuralgia. 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 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 Vumerity DR (delayed release) 231 milligram capsule to treat multiple sclerosis. 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 Gammagard 30 gram per 300 milliliter solution to treat common variable immunodeficiency, 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. Based on the information provided, we determined the drug may be eligible for coverage under Part B, under Medicare rules.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 a coverage determination request and a tiering exception request for Nucala 100 milligram per milliliter prefilled injection syringe to treat asthma. The Part D plan approved the request for coverage of the drug. However, the plan denied the tiering exception request. The plan 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 reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.As noted previously the drug has already been approved for coverage by the plan. Therefore, this review is for a tiering exception only. Nucala 100 milligram per milliliter prefilled injection syringe is a biologic drug on Tier 2 of the plans formulary. There are no biologics of the same type to treat the noted condition on the lower tiers of the plans formulary. If there are no biologics of the same type on a lower tier, the biologic drug is not eligible for a tiering exception. A physician reviewer determined that tiering exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a coverage determination request and a tiering exception request for Nucala 100 milligram per milliliter subcutaneous auto injection pen to treat asthma. The Part D plan approved the request for coverage of the drug. However, the plan denied the tiering exception request. The plan 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 reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.As noted previously the drug has already been approved for coverage by the plan. Therefore, this review is for a tiering exception only. Nucala 100 milligram per milliliter subcutaneous auto injection pen is a biologic drug on Tier 2 of the plans formulary. There are no biologics of the same type to treat the noted condition on the lower tiers of the plans formulary. If there are no biologics of the same type on a lower tier, the biologic drug is not eligible for a tiering exception. A physician reviewer determined that tiering exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine 1.3 percent patch to treat unspecified low back pain. 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, 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 Cortisporin TC ear suspension due to concern of infection after a partial bilateral ear cerumen impaction removal. 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 Dupixent 100 milligram per 0.67 milliliter injection to treat atopic dermatitis. 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.