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

At issue is coverage for Armodafinil 250 milligram tablet to treat multiple sclerosis fatigue. 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 Ozempic 0.25 or 0.5 milligram per dose (2 milligram per 3 milliliter) solution pen injector 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 reviewed all available documentation.Ozempic 0.25 or 0.5 milligram per dose (2 milligram per 3 milliliter) solution pen injector is a brand drug on Tier 3 of the plans formulary. There are no brand 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 Lidocaine 5 percent patch to treat unspecified pain. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Olopatadine 665 microgram per inhalation nasal spray to treat allergic rhinitis. 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 Tadalafil 5 milligram tablet to treat benign prostatic hyperplasia. 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 submitted documentation does not include medical records to fully support the indications in the Medicare approved compendia. This information was requested by the Part D plan with no medical records submitted. The documentation submitted at reconsideration also does not include medical records. As such, there is insufficient documentation available to establish that the requested drug has been prescribed for a medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Rinvoq ER (extended release) 30 milligram tablet to treat alopecia universalis. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Dayvigo 10 milligram tablet to treat insomnia. 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. The prescriber has 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. Specifically, the records show that the formulary alternatives Ramelteon and Trazodone were tried and failed. Therefore, a formulary exception is supported in this case.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 Lyrica 20 milligram per milliliter solution to treat fibromyalgia. 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 Xiidra 5 percent eye drops to treat keratoconjunctivitis sicca. 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 Dulera 100/5 microgram per actuation aerosol to treat bronchiectasis, uncomplicated. The Part D plan denied the request for coverage.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication. Additionally, the plan has a quantity limit for this drug of 1 per month.  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 Viberzi 100 milligram tablet to treat inflammatory bowel disease with diarrhea. 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 Eucrisa 2 percent ointment to treat mild to moderate atopic dermatitis. 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 Privigen 40 gram per 400 milliliter solution to treat common variable immunodeficiency (D83.9) and/or nonfamilial hypogammaglobulinemia (D80.1). 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 administration of intravenous and/or subcutaneous immune globulin therapy for the treatment of both common variable immunodeficiency (D83.9) and nonfamilial hypogammaglobulinemia (D80.1) would be covered under Medicare Part B. Please refer to the applicable Medicare Local Coverage Determination (LCD) for immune globulin therapy for the state of Alabama, which is LCD L34580 and the related Policy Article, PA A56718. Medicare rules state that any drug available for coverage under Medicare Part B cannot be covered under Part D. Therefore, the requested drug is not eligible for Medicare Part D coverage. Please note that this drug has already been approved under the enrollees Medicare Part B benefit. The authorization number is PA-B4936389. This authorization is valid from May 12, 2023, through December 31, 2023. Please submit the request through Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Cyclobenzaprine Hydrochloride 10 milligram tablet to treat chronic pain. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Hydroxyzine Hydrochloride 25 milligram tablets to treat anxiety. The Part D plan auto-forwarded the case to us for review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that the enrollee has satisfied the plans prior authorization coverage criteria. However, the prescriber did not respond to our request.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Sumatriptan Succinate 100 milligram tablets, 30 tablets per 30 days, to treat migraine headaches. The Part D plan denied the request for coverage. OR The Part D plan auto-forwarded the case to us for review. OR 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.During this review, 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, the prescriber did not respond to our request.The plans quantity limit for the requested drug is 9 tablets per 30 days. The prescriber has not provided patient-specific clinical rational as to why the amount allowed by the plan would be ineffective in treating the diagnosis and/or would be contraindicated. Furthermore, the submitted documentation does not support the medical necessity for an exception to the plans quantity limit for the drug. A physician reviewed the appeal and determined that the requested drug at the requested amount is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Ajovy 225 milligram per 1.5 milliliter solution as migraine prophylaxis. 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 submitted documentation supports the drug at issue is for the prevention of migraines in an enrollee that had daily vestibular migraines prior to initiating a migraine-preventative medication. 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 Pimecrolimus 1 percent cream to treat contact dermatitis, unspecified. The Part D plan auto-forwarded the case to us for review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that all formulary alternatives were tried and failed or were deemed contraindicated. We received additional documentation and included it in the review. 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 a tiering exception request for Ozempic 1 milligram per 0.75 milliliter pen injector to treat type 2 diabetes mellitus. 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.Ozempic is a brand drug on Tier 3 of the plans formulary. There are no brand 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 Victoza 2 pack 18 milligram per 3 milliliter with a purchase date of 3/22/2022 and adjustment amount due of $336.90 minus the amount owed to you of $158.80 for a total due to plan of $179.65. 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 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 record shows the plan reprocessed a claim for the requested drug that was originally purchased on 3/22/2022. The plan reprocessed the total amount due from the enrollee and $179.65 is due after the amounts owed to you by the plan were subtracted from the total due. 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. The claim submitted shows the purchase occurred on 3/22/2022. We have determined that the plan is correct in its calculation of additional copay amounts due to reconciliation of the enrollees true out of pocket accumulation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Eliquis 5 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 available documentation. The plans Evidence of Coverage states that reimbursement for drugs administered to an enrollee for an out-of-network provider is based on the amount paid for the drug less any deductible, copayment or coinsurance, the amount the physician charges, and the plans approved amount. The plan submitted documentation showing the enrollee was reimbursed for the plans share of the cost for the requested drug. Therefore, the documentation does not support any further reimbursement from the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fosfomycin 3 gram powder packet prescribed for urinary tract infection. The Part D plan denied your request.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. According to Medicare rules, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. According to the list, the manufacturer, Zambon USA, did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, we determined that the plan is not required to cover the Timolol Maleate. 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

You requested reimbursement for Bromocriptine 2.5 milligram tablet taken during a Part A stay. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plan denied your request for reimbursement because the drug was repackaged. The drug in question is repackaged by a distributer who is not the maker of the drug. Drugs that are considered repackaged are not covered by Part D. Furthermore, the National Drug Code (NDC) number (60687-0286-11) verified with the Food and Drug Administration that the NDC number is not valid. Therefore, the drug is not eligible for coverage under Medicare Part D. We determined the plan is not required to provide reimbursement for the Bromocriptine 2.5 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Venlafaxine Hydrochloride ER (extended release) 75 milligram capsule taken during a Part A stay. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plan denied your request for reimbursement because the drug was repackaged. The drug in question is repackaged by a distributer who is not the maker of the drug. Drugs that are considered repackaged are not covered by Part D. Furthermore, the National Drug Code (NDC) number (68084-0709-11) verified with the Food and Drug Administration that the NDC number is not valid. Therefore, the drug is not eligible for coverage under Medicare Part D. We determined the plan is not required to provide reimbursement for the Venlafaxine Hydrochloride ER (extended release) 75 milligram capsule.