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

At issue is coverage for Leukine 250 microgram injection powder for solution to treat Parkinson's 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. 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 Desvenlafaxine Succinate extended release 0 milligram tablet to treat general anxiety disorder. 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 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 Xtampza ER (Extended Release) 9 milligram capsule to treat chronic low back pain. 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 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 Azelastine/Fluticasone 137/50 microgram per actuation suspension to treat asthma. 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 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: Favorable

At issue is coverage for Varenicline Tartrate 1 milligram tablet, 1 tablet twice daily. The Part D plan denied the request for coverage because the prescriber indicated that the drug was not being prescribed as an aid to smoking cessation treatment.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. Additionally, the plan has prior authorization requirements for this drug that must be met before coverage will be provided. During this review, a request was submitted to the prescriber to clarify the condition being treated with the requested drug. We received additional documentation and included it in the review. The newly submitted documentation submitted by the prescriber indicates/clarifies that the requested drug has been prescribed as an aid to smoking cessation. The use of the requested drug to treat the noted condition is a medically accepted indication for the drug as outlined in the Medicare approved compendia. Furthermore, the use of the requested drug to treat the noted condition satisfies the plans prior authorization requirements for coverage of this drug. 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 Oxycodone Hydrochloride 10 milligram tablet. 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 clarify the diagnosis and to support that the medication is medically necessary and the amount of opioids are appropriate for the enrollee. However, the prescriber did not respond to our request.The record shows the plan has an opioid restriction in place for the enrollee. The documentation does not show the enrollee should be exempt due to cancer, hospice status, or end-of-life-care. In addition, the documentation does not have a prescribers statement that validates the opioid medication is medically necessary and safe for the enrollee. Therefore, the 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 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 provided diagnosis of testicular hypofunction, by itself, is not sufficient to determine if the requested drug has been prescribed for a medically accepted indication. During this review, we requested medical records and a prescriber statement to clarify the enrollees diagnosis and to address the plans coverage requirements for the drug. The prescriber did not respond to the request. 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 Brimonidine Tartrate prescribed for 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. The submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Tylenol to treat unknown diagnosis. 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. Tylenol 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: Favorable

At issue is Engerix-B injection prescribed for 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 pharmacy. 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 from the prescribers office and a proof of payment indicating full payment was made for the vaccine and administration fee. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocortisone Valerate prescribed for 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. The submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Apixaban 5 milligram oral tablet (generic alternative Eliquis 5 milligrams). The Part D plan denied your request because the drug was not purchased in the United States. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted.The record shows you purchased the drug from NorthWestPharmacy.com located in Langley, British Columbia, Canada.We determined that the plan is not required to cover generic alternative Eliquis 5 milligrams because it was purchased in Canada. Drugs purchased outside of the United States are excluded from coverage. This decision does not address the medical necessity or appropriateness 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 Progesterone bulk powder compounded drug. The Part D plan denied/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.Drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The requested drug is considered a bulk powder/ or is consistent of bulk powder ingredients and is excluded from coverage under Part D. 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 Isopto Tears/Acetylcysteine/Sodium Hydroxide compounded drug. 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 plan to provide reimbursement for a medication purchased from a network pharmacy. The plan's Evidence of Coverage states, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the documentation does not include the National Drug Code (NDC). Therefore, we determined that the plan is not required to reimburse the enrollee without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Juluca 50/25 milligram tablets to treat unknown diagnosis. 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.Juluca is included on Tier 5 of the plans formulary. Tier 5 of the formulary is the tier reserved for specialty drugs. The Specialty tier is exempt from tiered cost-sharing expectations, per Medicare rules. Therefore, this drug is not eligible for a tiering exception. The requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Hyalgan 20 milligram per milliliter solution to treat osteoarthritis of knees. 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 documentation indicates that the requested drug is considered a device which is a Part B benefit. Any drug available for coverage under Medicare Part B cannot be covered under Part D, per Medicare rules. Therefore, the requested drug is not eligible for 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. Please submit the request for coverage through Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Zenzedi 10 milligram tablet to treat attention deficit hyperactivity disorder (ADHD). 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: Favorable

At issue is coverage for Fentanyl 25 microgram per hour transdermal 72-hour patch, 10 patches per 30 days, to treat pain severe enough to require daily, around-the-clock, long-term opioid treatment/chronic pain. The Part D plan denied the request for coverage because the following prior authorization requirement was not met: there was not confirmation that non-opioid therapies have been tried and these therapies will be continued in combination with opioids.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 medical records submitted at reconsideration support that non-opioid therapies have been tried and these therapies will be continued in combination with opioids. The progress notes submitted at reconsideration show that the enrollee has had previous LESIs (lumbar epidural steroid injections) for the chronic pain. Furthermore, the progress notes indicate that the enrollees condition is also treated with Soma, Hydrocortisone, and physical therapy. The available documentation supports that the plans remaining prior authorization requirements have been met, as well. Specifically, the enrollee is not opioid naive; the prescriber has checked the patient history of controlled substance prescriptions via the state prescription drug monitoring program; the prescriber has discussed risks and realistic benefits of opioid therapy with the enrollee; and according to the prescriber, there is a treatment plan in place that includes goals for pain and function and it is reassessed regularly. 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 Eliquis 5 milligram tablet to reduce the risk of stroke and systemic embolism associated with atrial fibrillation. 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 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: Partially Favorable

At issue is coverage and a tiering exception request for Farxiga 5 milligram tablet. The Part D plan denied the request for coverage and a tiering exception because the prescriber did not provide a diagnosis for the drug. 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. At reconsideration, the submitted medical records indicate that the requested drug has been prescribed to treat type 2 diabetes mellitus. The use of the requested drug to treat the noted condition is a medically accepted indication for the drug as outlined in the Medicare approved compendia. Therefore, coverage for the drug is supported.Farxiga is a brand drug on Tier 4 of the plans formulary. The prescriber has not provided patient-specific clinical rationale as to why the brand drugs of the same type on the lower tiers of the plans formulary (Invokana and Jardiance) are contraindicated. Additionally, the submitted documentation does not support that the enrollee has tried and failed 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 eligible for Part D coverage. However, the drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Prolia 60 milligram per milliliter solution to treat postmenopausal osteoporosis. 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 supports that all of the plans requirements for coverage have been satisfied. Specifically, the provider has submitted a new prior authorization form and a statement that indicates the member will not be taking any other drug in combination to treat postmenopausal osteoporosis. 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 Miconazole Nitrate powder to treat candidiasis of skin and nails. 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 excluded from Part D coverage because the provided National Drug Code (NDC) for the drug is not listed on the United States Food and Drug Administration (FDA) NDC SPL Data Element (NSDE) file, or the NDC listed on NSDE file has a marketing end date prior to date of service in review. 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 Lurasidone Hydrochloride 40 milligram tablet to treat major depressive disorder, recurrent, moderate. 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. 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.