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

At issue is coverage for Vyzulta 0.024 percent ophthalmic solution to treat primary open angle glaucoma, bilateral, mild stage. 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 the enrollee has satisfied the plans step therapy requirement. However, the prescriber did not respond to our request.The plan has a step therapy requirement that must be met before coverage of this drug will be provided. The submitted documentation does not support that the plans step therapy requirement has been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans step therapy requirement.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 Lidocaine 5 percent patch to treat the enrollee's condition. 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.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that the enrollee has satisfied the plans prior authorization coverage criteria. However, the prescriber did not respond to our request. 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. As such, there is insufficient documentation available to establish that the requested drug has been 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 coverage for Megestrol Acetate 400 milligram per 10 milliliter oral suspension. 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.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. During this review, a request was submitted to the prescriber to provide the diagnosis and supporting medical records and to address the plans coverage requirements for this drug. The prescriber did not respond to the request. Without a diagnosis, it cannot be established that the drug has been 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 coverage for Stelara 130 milligram per 26 milliliter solution to treat ulcerative colitis . 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 the enrollee has satisfied the plans prior authorization coverage criteria However, the prescriber did not respond to our request. 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 Quetiapine Fumarate 50 milligram tablet to treat agitation secondary to traumatic brain injury. 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. During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the diagnosis being treated and the quantity prescribed was medically necessary for the enrollee. We received additional documentation and included it in the review.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. As this drug is ineligible for Part D coverage, it is not eligible for consideration for a quantity exception.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 Calonal 300 milligram tablet prescribed to treat the enrolllee's condition. 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 shows the enrollee purchased drugs from a pharmacy outside of the United States. Drugs purchased outside of the United States are excluded from coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carbocysteine 500 milligram tablet prescribed to treat the enrollee's condition. 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 shows the enrollee purchased drugs from a pharmacy outside of the United States. Drugs purchased outside of the United States are excluded from coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Medicon 15 milligram tablet prescribed to treat the enrollee's condition. 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 shows the enrollee purchased drugs from a pharmacy outside of the United States. Drugs purchased outside of the United States are excluded from coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Tsumura Bakumondoto extract 9gm granule to treat not provided . 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 submitted documentation shows the enrollee purchased drugs from a pharmacy outside of the United States. Drugs purchased outside of the United States are excluded from coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Innohep/Tinzaparin Sodium 4500 units per 0.45 milliliter injection syringe to treat closed fracture of femur. The Part D plan denied the request for coverage.milliliterWe received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The submitted documentation shows the enrollee purchased drugs from a pharmacy outside of the United States. Drugs purchased outside of the United States are excluded from coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tramdol/Acetaminophen 37.5/325 milligram tablet prescribed to closed fracture of femur. 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. The submitted documentation shows the enrollee purchased drugs from a pharmacy outside of the United States. Drugs purchased outside of the United States are excluded from coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrex 50/0.5 milliliter injection for a vaccine. 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 record shows the enrollee requested reimbursement of a total of $304 for the Shingrex vaccine. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug was not provided. Only the amount owed is shown on the bill submitted. Therefore, we determined that the plan is not required to provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Licart 1.3 percent patch to treat cervical spondylosis and lumbar spondylosis with radiculopathy. 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 noted conditions are off-label uses for the requested drug. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. Therefore, the drug is being prescribed for non-medically accepted indications. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Partially Favorable

At issue is coverage for Oxycodone 30 milligram tablet to treat the enrollee's condition. 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, wereviewed all available documentation.The plans Evidence of Coverage states, reimbursement for drugs administered to an enrollee, are based on the amount paid for the drug, less any deductible, copayment or coinsurance, less the amount the physician charges, and the plans approved amount. The plan submitted documentation showing the enrollee was reimbursed for the plans share of the cost for the requested drug and administration fee. Therefore, we determined that the plan is not required to provide further reimbursement for dates of service January 3, 2023, February 15, 2023, April 20, 2023, May 18, 2023, and June 15, 2023.The submitted documentation shows the enrollee filled prescriptions for the requested drug at a network pharmacy for dates of service February 3, 2023, February 23, 2023, and March 23, 2023. The plan denied these dates of fill at point of sale for exceeding plan limitations. However, the plan has approved a quantity up to 180 every 30 days, as prescribed by the physician. We determined that the plan is required to reimburse the enrollee for their share of the cost for the requested drug, based on the enrollee's cost share stage on the date of purchase. Therefore, the reimbursement criteria have been met for dates of service February 3, 2023, February 23, 2023, and March 23, 2023.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Norvasc 2.5 milligram tablet to treat essential hypertension. 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 Sodium Chloride 1 gram tablet to treat the enrollee's condition. 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.Sodium Chloride 1 gram tablet is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. 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 a tiering exception request for Lasix to treat the enrollees 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 available documentation.Lasix is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost-sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception. A physician 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 Hydrocortisone Acetate 25 milligram rectal suppository to treat irritable bowel syndrome. 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. Hydrocortisone Acetate is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. 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 Vyndamax 61 milligram capsule to treat transthyretin (TTR) amyloidosis. 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 confirm 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 Freestyle Libre 2 Sensor. The Part D plan denied the request for coverage.Medicare classifies home blood glucose monitors as durable medical equipment. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment. Additionally, payment will be made under Medicare Part B for the supplies necessary for the effective use of durable medical equipment, including,Freestyle Libre 2 Sensor. Any drug/item available for coverage under Medicare Part B cannot be covered under Part D, per Medicare rules. As such, the requested item is not eligible for Medicare Part D coverage.This decision does not address the medical necessity of the item. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit the request for coverage through Medicare Part B.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Mektovi 15 milligram tablet to treat metastatic melanoma. 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 compendium, National Comprehensive Cancer Network (NCCN), includes an off-label citation for the use of the requested drug to treat metastatic melanoma as a single agent for NRAS mutated tumors that have progressed following immune checkpoint inhibitor therapy. Therefore, the requested drug is being prescribed to treat a medically accepted indication.The plan has prior authorization requirements that must be met before coverage of this drug is provided. However, the plans prior authorization requirements are diagnosis-specific and not related to the condition being treated. Since the condition being treated is a medically accepted indication outlined in NCCN, an exception to the plans diagnosis-specific coverage requirements is supported. 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 coverage for Venclexta 10/20/30 milligram tablet to treat chronic lymphocytic leukemia, in combination with Pirtobrutinib. 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 Pimecrolimus 1 percent cream to treat urticaria and lichen planus. 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 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 compounded dru Betahistine Dihydrochloride 100 percent powder used to treat Menieres disease, right ear 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.Betahistine Dihydrochloride 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. Drugs that are not FDA-approved do not meet the definition of a Part D drug and are excluded from Part D coverage. Therefore, the requested drug is excluded from Medicare Part D coverage.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: Favorable

At issue is coverage for Benlysta 200mg/ml injection to treat systemic lupus erythematosus. 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 plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation supports that all of the plans requirements for coverage have been satisfied. Specifically, the prescriber submitted a reauthorization request along with records and the patient is receiving standard therapy for systemic lupus erythematous along with Benlysta. In addition, there are no contraindications noted and the patient shows improvement on current treatment. Therefore, the plans prior authorization requirements have been met and coverage for the drug is supported.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 coverage for Inflectra 100 milligram intravenous solution to treat juvenile rheumatoid polyarthritis, seronegative. 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 reviewed all available documentation. The submitted documentation indicates that the requested drug is being provided incident to a physicians service. Drug furnished incident to a physicians service are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from 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.