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

At issue is Dupixent 300 milligram per 2 milliliter pen, quantity 6 per 84 day supply, to treat the enrollees diagnosis of other 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 limits the amount of Dupixent 300 milligram per 2 milliliter pen provided as a 30-day supply. 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 Ajovy 225 milligram per 1.5 milliliter syringe to treat migraine without aura, intractable, without status migrainosus. 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 and 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 Prevymis 480 milligram tablet prescribed for prophylaxis of cytomegalovirus disease in an enrollee with a history of lung transplant. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug is not eligible for coverage under Medicare Part D.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 2 milligram sublingual tablet to treat chronic pain associated with lumbar radiculopathy and lumbar intervertebral disc degeneration. 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. Medical records from date of service December 1, 2022 were provided with the request for reconsideration. These medical records document that the requested drug is being prescribed for the treatment of chronic pain.  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 Victoza 18 milligram per 3 milliliter pen injector to treat type 2 diabetes mellitus. 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 prescriber has not indicated that all alternatives required by the plan have been tried and failed, or why the plans required step therapy drugs would likely not be as effective as the requested drug.  A physician reviewer determined that neither step therapy nor step therapy exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tyvaso Starter Kit 0.6 milligram per milliliter nebulizer solution to treat pulmonary hypertension associated with interstitial lung disease. The case was auto-forwarded by the Part D plan. The plan states the drug has been approved under Medicare Part B.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 records indicate the drug will be used in a nebulizer at home. This drug is not eligible for coverage under Part D drug benefits. However, this drug may be covered under Medicare Part B benefits. We determined that the Part D plan is not required to cover Tyvaso Starter kit.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Levocarnitine 330 microgram tablet to treat inborn error of metabolism, Cobalmin C deficiency. 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 coverage criteria that must be met prior to approval. The criteria indicates the enrollee must have a Food and Drug Administration approved indication. The Medicare approved compendia contain a citation to support the use of the drug for the enrollees noted diagnosis. Therefore, an exception to the plans coverage criteria is medically necessary.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 Kineret 100 milligram per 0.67 milliliter solution to treat recurrent gout flares. 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 coverage for First-Omeprazole 2 milligram per milliliter suspension to treat gastroesophageal reflux disease with esophagitis in an enrollee with dysphagia secondary to oral cancer. 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. The requested drug has not been approved by the Food and Drug Administration (FDA). Drugs that have not been approved by the FDA do not meet the definition of a Part D drug and 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 requested 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 Nulojix 250 milligram vial prescribed for renal transplant rejection prophylaxis in an enrollee who is Epstein-Barr virus (EBV) seropositive. The Part D plan denied the request for coverage because the drug would be available for coverage under Medicare Part B. 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 Medicare Part B local coverage determination rules state that parenteral Belatacept (Nulojix) is not proven to be safe when administered in the home setting, and therefore will be denied under Medicare Part B as not medically necessary when provided in that setting. The case record indicates that Nulojix will be administered in the home. Nulojix would therefore not be eligible for coverage under Medicare Part B in this case. However, Medicare Part D requires the requested drug to be given for a medically accepted indication outlined in the Medicare approved compendia. The Medicare approved compendia and the drug product labeling indicate that Nulojix should be used in conjunction with Basiliximab induction, Mycophenolate Mofetil, and corticosteroids. The submitted medical records do not support that the Nulojix is going to be administered in conjunction with Basiliximab induction, Mycophenolate Mofetil, and corticosteroids. As such, the requested drug, as prescribed, is being used 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 Quinine Sulfate 324 milligram capsules to treat intractable nocturnal leg cramps. 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 Mounjaro 5 milligram per 0.5 milliliter injector pen to treat type 2 diabetes mellitus with unspecified complications. 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 Pulmozyme 2.5 milligram per 2.5 milliliter nebulizer solution to treat an enrollee with cystic fibrosis. 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 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 records indicate the drug will be used in a nebulizer at home. This drug is not eligible for coverage under Part D drug benefits. However, this drug may be covered under Medicare Part B benefits. We determined that the Part D plan is not required to cover Pulmozyme nebulizer solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gemcitabine Hydrochloride 1 gram intravenous solution. 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 plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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 Tremfya 100 milligram per milliliter syringe to treat psoriasis vulgaris. 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 Cyclobenzaprine Hydrochloride 10 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, 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 a covered diagnosis and that the enrollee has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information.At reconsideration a diagnosis of acute musculoskeletal condition was given. However, no documentation was provided by the prescriber to support this diagnosis. We requested information from the prescriber but no information was received. We are not able to determine whether the requested drug(s) was prescribed for a medically accepted indication. Therefore, the 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 Mexiletine 150 milligram capsule. 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.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support a covered diagnosis and that all formulary alternatives were tried and failed or were contraindicated. However, we did not receive the requested information.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 Xifaxan 550 milligram tablet to treat other specified diseases of intestine. 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.A request was submitted to the prescriber to clarify the diagnosis and to submit medical records with the medical history and current treatments. We did not receive the information. 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 Droxidopa 100 milligram capsules to treat multi-system degeneration of the autonomic nervous system (G90.3), orthostatic hypotension (I95.1), neurologic hypertension, and neurogenic orthostatic hypotension (nOH). 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 that the enrollee has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. No documentation was provided by the prescriber. We requested information from the prescriber but no information was received. The submitted documentation does not satisfy the plans coverage criteria.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 Ozempic (1 milligram dose) solution pen-injector 4 milliliters for 28 days to treat type 2 diabetes mellitus without complications. 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 that the quantity prescribed was medically necessary for the enrollee. However, we did not receive the requested information.The plan limits the amount of Ozempic (1 milligram dose) to 3 milliliters for 28 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 Biest 0.375 milligram, Progesterone 100 milligram, Testosterone .05 milligram per milliliter Versabase cream prescribed 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. This includes the case file from the plan, and any information submitted at the reconsideration level.Medicare rules state, that bulk powders for pharmaceutical compounding do not satisfy the definition of a Part D drug and are not covered by Part D. In addition, over the counter drugs are excluded from coverage under Medicare Part D. The requested compounded drug includes both bulk powder ingredients and over the counter ingredients and is therefore, excluded from coverage and not eligible for reimbursement. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estriol micronized 0.01 milligram vaginal suppository compound prescribed 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. This includes the case file from the plan, and any information submitted at the reconsideration level.Medicare rules state, that bulk powders for pharmaceutical compounding do not satisfy the definition of a Part D drug and are not covered by Part D. In addition, over the counter drugs are excluded from coverage under Medicare Part D. The requested compounded drug includes both bulk powder ingredients and over the counter ingredients and is therefore, excluded from coverage and not eligible for reimbursement. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Polymyxin B Sulfate 10,000 unit/gram, Mupirocin 1 percent, Hydrocortisone 1 percent compound cream prescribed to treat an unspecified diagnosis. 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The plan provided documentation showing the enrollee requested reimbursement for the compound drug. However, the pharmacy's Universal Claim Form for a Compounded Medication is not provided listing each ingredient, noting if the ingredient is bulk powder, the dosage, and the National Drug Codes (NDCs) of each ingredient. Therefore, we determined the plan is not required to cover or reimburse the enrollee for the compounded drug. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment or reimbursement cannot be made under the Medicare Part D benefit without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Erythromycin 5 milligram per gram ophthalmic ointment prescribed to prevent eye infection post surgery. 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. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted claim documentation shows the enrollee received the first fill of the requested ointment on November 8, 2022. The next available fill date was November 15, 2022. However, a second fill for the ointment was received by the enrollee on November 14, 2022. According to the plans Evidence of Coverage, limits and restrictions are placed on drugs that are refilled too soon. Therefore, the claim for fill date November 14, 2022 was rejected at point of sale for refill too soon, and the amount charged to the enrollee was an out-of-pocket expense. We determined this drug was paid correctly and no further reimbursement is required by the plan.