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

At issue is coverage for Repatha Pushtronex System 420 milligram per 3.5 milliliter solution cartridge to treat mixed hyperlipidemia and coronary artery disease of native artery with stable angina pectoris. 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 Clindamycin Phosphate 1 percent lotion to treat chronic folliculitis on buttocks and legs. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication. Of note, a formulary exception or quantity limit exception cannot be addressed for a drug that is not eliigible for Part D coverage.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 Glucerna Shake liquid to treat severe dysphagia with risk of aspiration and diabetes. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. Glucerna Shake 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 Nucala 100 milligram per milliliter auto injector to treat severe eosinophilic asthma. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. 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 coverage for Lenalidomide 5 milligram capsule to treat myelodysplastic syndrome with 5q deletion. The Part D plan denied the request for coverage because all of the plans prior authorization requirements were not met, as the prescriber did not indicate whether or not if the enrollee had symptomatic anemia.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. At reconsideration, the submitted prescriber statement and medical records clarify that the enrollee does have symptomatic anemia. The submitted documentation supports that all of the plans remaining requirements for coverage have been satisfied, as well. 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 Procrit 20,000 unit per milliliter solution to treat iron deficiency anemia in chronic kidney disease not on dialysis. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Aldosetron Hydrochloride 1 milligram tablet to treat severe irritable bowel syndrome with diarrhea in a male enrollee. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Acetazolamide ER (extended release) 500 milligram capsule to treat primary open angle 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 available documentation.Acetazolamide 500 milligram extended release capsule is a generic drug on Tier 3 of the plans formulary. The prescriber has not provided patient-specific clinical rationale as to why all of the generic drugs of the same type on the lower tiers of the plans formulary to treat the enrollees condition are contraindicated. Additionally, the submitted documentation does not indicate that the enrollee has tried and failed all of the lower-tiered alternative drugs. Therefore, the tiering exception requirements have not been met.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 Silodosin 4 milligram capsule to treat benign prostatic hyperplasia with lower urinary tract symptoms. 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 Wegovy 0.25 milligram per 0.5 milliliter solution auto-injector prescribed to treat prediabetes and to promote weight loss in an enrollee with obesity. 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 for the treatment of prediabetes. In addition, drugs prescribed to treat obesity and/or to promote weight loss are excluded from the Part D coverage.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 Creon DR (delayed release) 12,000 unit capsule to treat chronic pancreatic insufficiency. 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.Creon DR is a brand biologic drug on Tier 3 of the plans formulary. There are no brand biologic drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Erythromycin 250 milligram tablet prescribed to increase gastric motility/promote gastric emptying in an enrollee with gastroparesis. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Testosterone 1.62 percent gel to treat testicular hypofunction. 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 Xeljanz XR (extended release) 11 milligram tablet to treat rheumatoid arthritis. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, 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 drug on the plans formulary, Rinvoq tablet extended release, 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 the formulary alternative drug. 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 a tiering exception request for Buprenorphine Hydrochloride/Naloxone Hydrochloride 4-1 milligram film to treat opioid use disorder, 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 reviewed all available documentation.Buprenorphine Hydrochloride/Naloxone Hydrochloride 4-1 milligram film is a generic drug on Tier 2 of the plans formulary. There are no generic drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Dihydroergotamine Mesylate 4 milligram per milliliter solution with a quantity of 8 milliliters per day. 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 indicate 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 evidence of a prescribed diagnosis. This information was requested by the Part D plan with no response from the prescriber/prescribers office. The documentation at reconsideration also does not include clinical evidence or a prescribed diagnosis. As such, there is insufficient documentation available to establish that the requested drug has been prescribed for a medically accepted indication. In addition, the amount requested is over the plans limit and a quantity exception cannot be approved for a drug not eligible for Part D coverage.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 Farxiga 5 milligram tablet to treat type 2 diabetes mellitus with diabetic chronic kidney disease. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that all formulary alternatives were tried and failed or were deemed contraindicated. However, the prescriber did not respond to our request.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 Glimepiride 2 milligram tablet prescribed for the enrollee's condition. 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 enrollee requested the Part D plan to provide reimbursement for the requested drug. However, there is missing information needed to consider the request. The required information includes the Pharmacy name, drug name with quantity, Pharmacy receipt indicating the enrollee paid for the drug, the National Drug Code (NDC) of the requested drug, and the prescribing physicians name, address and National Provider Identifier (NPI) number. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azithromycin 250 milligram tablets. The Part D plan denied the request.We performed 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.According to the Food and Drug Administration, the drug at issue has a National Drug Code that is not eligible under Part D, because the manufacturer does not have a current registration for the drug. Therefore, we determined 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 Topiramate 25 milligram tablets. The Part D plan denied the request.We performed 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.According to the Food and Drug Administration, the drug at issue has a National Drug Code that is not eligible under Part D, because the manufacturer does not have a current registration for the drug. Therefore, we determined 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 Atorvastatin Calcium 20 milligram tablets. The Part D plan denied the request.We performed 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.According to the Food and Drug Administration, the drug at issue has a National Drug Code that is not eligible under Part D, because the manufacturer does not have a current registration for the drug. Therefore, we determined 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 reimbursement for Phenazopyridine 200 milligram tablet. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plans 2023 Evidence of Coverage states, reimbursement for drugs is based the total cost of covered drugs, minus the required deductible, copay, or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The claim information shows the cost of the drug was more than the plan approved amount. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Cefazolin Sodium 10 gram injection solution. 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 self-administered drugs during a hospital stay. The plans 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. The enrollee provided a statement from the hospital indicating full payment was made for the drug at issue. In addition, a valid National Drug Code was provided for the drug at issue, 60505-6143-4. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Ertapenem Sodium 1 gram injection solution. 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 self-administered drugs during a hospital stay. The plans 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. The enrollee provided a statement from the hospital indicating full payment was made for the drug at issue. In addition, a valid National Drug Code was provided for the drug at issue, 63323-8232-0. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levothyroxine Sodium 150 microgram tablets. The Part D plan denied the request.We performed 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.According to the Food and Drug Administration, the drug at issue has a National Drug Code that is not eligible under Part D, because the manufacturer does not have a current registration for the drug. Therefore, we determined 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.