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

At issue is a tiering exception request for Trelegy Ellipta 200/62.5/25 microgram per actuation to treat an unspecified diagnosis. 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 coverage for Valium 10 milligram tablet to treat depression, anxiety and panic disorder. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.For the drug at issue to be covered under Medicare Part D, the manufacturer must participate in the Medicare Coverage Gap Discount Program. The manufacturer of this drug is not participating in the program. Therefore, the drug is excluded from Part D coverage.This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ipratropium/Albuterol 0.5/2.5 milligram per 3 milliliter nebulizer ampule. 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.The record shows the Ipratropium/Albuterol is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover the Ipratropium/Albuterol. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omega 3-Acid Ethyl Esters 1 gram capsules to treat dyslipidemia. 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

We have dismissed your drug benefit request for Lovaza 1 gram capsules 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 Lidocaine 1 percent gel to treat neuropathic pain. 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. However, we did not receive the requested information.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.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 Fosamax Plus D 70 milligram/2800 unit tablets to treat other specified disorders of bone density and structure, unspecified site. 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 all formulary alternatives were tried and failed or were contraindicated. 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 is not eligible for coverage under Medicare Part D.Additionally, 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 Buprenorphine Hydrochloride/Naloxone Hydrochloride 8 milligram/2 milligram film (56 films per 14 days) to treat opioid dependence. 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.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the quantity prescribed was medically necessary for the enrollee. However, we did not receive the requested information.The plan limits the amount of Buprenorphine Hydrochloride/Naloxone Hydrochloride to 90 films 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

At issue is Lipitor 20 milligram tablets to treat lipid storage 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.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed or were contraindicated. However, we did not receive the requested information.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 Tagrisso 80 milligram tablets to treat the enrollees condition. The Part D plan denied the request. We performed 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 record shows that the enrollee was registered with a patient assistance program at the time the drug at issue was prescribed. The Medicare Part D drug plan cannot cover a drug that is already covered through a patient assistance program. We determined that the plan is not required to cover the drug at issue. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 49 milligram/51 milligram tablets to treat congestive heart failure. 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. The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix 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 of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the vaccine was provided by the prescriber and administered in the prescribers office. The plan's Evidence of Coverage states, that 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. However, proof of payment by the enrollee in the form of a receipt was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Vaqta 0.5 milliliter suspension prescribed for hepatitis A vaccination. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the vaccine at the prescriber's office. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or prescribers office. 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. The enrollee provided a statement dated June 15, 2022 from the prescribers office indicating full payment was made for the vaccine and administration fee. Therefore, we determined the plan is required to reimburse the enrollee, based on the enrollee's cost share stage less the amount the prescriber charges and what the plan approves for the vaccine and administration fee.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brimonidine Tartrate 0.2 percent Timolol 0.5 percent drop prescribed to treat glaucoma. 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 documentation showing the requested drug was approved as a formulary exception and therefore, ineligible for a tier exception (co-pay reduction). We determined the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Praluent 150 milligram per milliliter subcutaneous auto injection pen, 2 pens per 28 days. 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 documentation submitted.During this review, we requested additional documentation from the prescriber. Specifically, we requested medical records and a prescriber statement to address the plans coverage requirements for the drug and to provide supporting medical records. We received additional documentation and included it in the review. The newly submitted documentation confirms that the plans prior authorization requirements for coverage of the requested drug have been met. The submitted medical records indicate that the requested drug is being prescribed to treat hyperlipidemia in an enrollee with atherosclerotic cardiovascular disease. This is a medically accepted indication for the drug outlined in the Medicare approved compendia. The prescriber has indicated that this is a continuation of therapy with the requested drug, which was started on June 1, 2017. For continuation of therapy, the plan requires that the enrollee continues to receive concomitant maximally tolerated statin (unless contraindication or individual is statin intolerant) and confirmation (verbal or written attestation) of low density lipoprotein (LDL) reduction. The submitted prescriber statement (written attestation) states, He [the enrollee] has been recommended to maintain a goal LDL of less than 70 mg/dL [milligrams per deciliter]. He is unable to tolerate a higher dose of the rosuvastatin due to statin myopathy. Therefore, the patient has been treated with Praluent and with this medication has been able to achieve the recommended goal LDL. His most recent lipid profiles reflect his LDL values on the current regimen of rosuvastatin 10 mg daily and Praluent.Therefore, the newly submitted documentation supports the plans requirements for continuation of therapy for the requested drug have been satisfied. In addition, the amount requested does not exceed the plans quantity limit for the drug. As such, 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 a direct member reimbursement request for Dicyclomine Hydrochloride 20 milligram tablets. The Part D plan auto-forwarded the request.We received the submitted documentation to perform an independent and de novo review.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a direct member reimbursement request for Ondansetron x4 milligram orally disintegrating tablet. The Part D plan auto-forwarded the request.We received the submitted documentation to perform an independent and de novo review.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Besremi 500 microgram per milliliter injection solution to treat post essential thrombocythemia myelofibrosis. 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. Medicare-approved compendia do not contain any citations to support the use of the requested drug as prescribed, for treatment of the noted diagnosis. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, 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 Ondansetron 4 milligram orally disintegrating tablet to treat vomiting and gastritis. 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 Clobetasol Propionate 0.05 percent cream to treat dermatitis, 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. 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: Partially Favorable

At issue is Viberzi 75 milligram tablet with a quantity of 180 tablets per 90 days to treat irritable bowel syndrome with diarrhea. 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 address the prior authorization requirements and the plans quantity limit of 60 tablets per 30 days. We received additional information and included it in the review. The documentation satisfies the plans coverage criteria. The prescriber indicates the drug is requested for irritable bowel syndrome with diarrhea and there is not a contraindication noted and the provided medical records support this information. The use of the requested drug to treat the provided diagnosis is supported in the Medicare approved compendia. However, there was no reply to the quantity limit questions as to why a 90 day supply of this drug is required. The plan limits this specialty drug to a 30 day supply with a quantity of 60 tablets. The requested amount of 180 tablets per 90 days cannot be approved.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage. However, the 90 day supply of the drug is over the plans quantity limit. Therefore, a partial approval has been made for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 30 milligram tablet to treat psoriasis vulgaris. 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.