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

At issue is Palonosetron 0.25-milligram/2-milliliters Vial to treat nausea and vomiting due to chemotherapy. The Part D plan denied the request. The requested drug is not on the plans formulary. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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.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 medical records do not support why other drugs on the plans formulary would not work for you.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 Doxepin Hydrochloride 10-milligram capsules to treat pruritus, unspecified related to postherpetic neuralgia. 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 a tiering exception request for Repatha 140-milligram/milliliter solution prefilled syringe to treat mixed hyperlipidemia and coronary artery disease. 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.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amphetamine/Dextroamphetamine 30-milligram tablets to treat unspecified chronic fatigue. The Part D plan denied the request. The plan further denied a quantity limit exception.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, and a quantity limit exception cannot be granted.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 Myrbetriq ER 50-milligram tablets to treat overactive bladder. 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.Myrbetriq ER is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armour Thyroid 60-milligrams tablet to treat hypothyroidism. 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.Drugs that are not approved by the Food and Drug Administration (FDA) are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 75 milligram capsules to treat phantom limb syndrome with pain and causalgia of bilateral lower limbs. 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 Atorvastatin Calcium 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.Reimbursement was requested for Atorvastatin Calcium given to the enrollee while in the hospital. We researched Medicare resources and found that the repackaged drug Atorvastatin Calcium has a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover the Atorvastatin Calcium. 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 Hydrocodone Bitartrate-Acetaminophen 325-10-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.Reimbursement was requested for Hydrocodone Bitartrate-Acetaminophen given to the enrollee while in the hospital. We researched Medicare resources and found that the repackaged drug Hydrocodone Bitartrate-Acetaminophen has a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover the Hydrocodone Bitartrate-Acetaminophen. 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 Hydrocodone Bitartrate-Acetaminophen 325-5-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 documentation submitted including the case file from the plan and any information submitted at the reconsideration level.Reimbursement was requested for Hydrocodone Bitartrate-Acetaminophen given to the enrollee while in the hospital. We researched Medicare resources and found that the repackaged drug Hydrocodone Bitartrate-Acetaminophen has a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover the Hydrocodone Bitartrate-Acetaminophen. 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 Hydroxyzine Hydrochloride 25-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.Reimbursement was requested for Hydroxyzine Hydrochloride given to the enrollee while in the hospital. We researched Medicare resources and found that the repackaged drug Hydroxyzine Hydrochloride has a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover the Hydroxyzine Hydrochloride. 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 Levothyroxine Sodium 25-microgram 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.Reimbursement was requested for Levothyroxine Sodium given to the enrollee while in the hospital. We researched Medicare resources and found that the repackaged drug Levothyroxine Sodium has a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover the Levothyroxine Sodium. 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 Losartan Potassium 50-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.Reimbursement was requested for Losartan Potassium 50-milligram given to the enrollee while in the hospital. We researched Medicare resources and found that the repackaged drug Losartan Potassium has a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover the Losartan Potassium. 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 Metaxalone 800-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.Reimbursement was requested for Metaxalone given to the enrollee while in the hospital. We researched Medicare resources and found that the repackaged drug Metaxalone has a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover the Metaxalone. 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 Metoprolol Succinate ER 100-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.Reimbursement was requested for Metoprolol Succinate ER given to the enrollee while in the hospital. We researched Medicare resources and found that the repackaged drug Metoprolol Succinate ER has a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover the Metoprolol Succinate ER. 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 Tamsulosin Hydrochloride 0.4-milligram capsule. 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.Reimbursement was requested for Tamsulosin Hydrochloride given to the enrollee while in the hospital. We researched Medicare resources and found that the repackaged drug Tamsulosin Hydrochloride has a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover the Tamsulosin Hydrochloride. 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 a tiering exception request for Varenicline 1-milligram tablets to treat tobacco use disorder. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.This drug is being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trelegy Ellipta 100/62.5/25-microgram inhalation powder. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted.Trelegy Ellipta is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec 75-milligram disintegrating tablet for migraine prophylaxis. The Part D plan denied the request. The requested drug is not on the plans formulary.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 provided patient specific clinical rationale, supported by documentation, as to why all formulary alternatives required by the plan would likely not be as effective as the requested drug for this diagnosis, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not medically necessary. 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 Albuterol Sulfate HFA 90-microgram per actuation aerosol inhaler. 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. During the review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee has satisfied the requirements for coverage of the requested drug. We received additional documentation and included it in the review.The newly submitted medical records indicate that the Albuterol Sulfate HFA inhaler has been prescribed for the treatment of chronic obstructive pulmonary disease. This is a medically accepted indication for the use of the drug, as outlined in the Medicare approved compendia. The plan has no additional coverage requirements for the drug. The plans quantity limit for the drug is 17 grams (2 inhalers) per 30 days, which would be 6 inhalers per 90 days. The prescriber is requesting 3 inhalers per 90 days (1 inhaler per 30 days). Therefore, the plans quantity limit has not been exceeded. As such, payment for the drug can be allowed. 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 Repatha 140-milligram/milliliter solution auto-injector to treat unspecified diastolic heart failure and mixed hyperlipidemia. 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 alternative drugs provided on the plans formulary list 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 Budesonide 3-milligram Enteric Coated capsule to treat Behcets syndrome. 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.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 condition. 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 a tiering exception request for Ozempic 0.25-0.5-milligram/dose Pen 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 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.Ozempic is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the request and determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5-milligram tablets to treat chronic heart failure with persistent 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 documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be approved. The submitted documentation does not support that all of the plans coverage requirements 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: Unfavorable

At issue is Repatha Sureclick 140-milligram pen injector to treat coronary artery disease. 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 requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Folic Acid 1-milligram tablets for the prevention of toxicity in long-term use of Methotrexate. 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.Drugs prescribed for use as vitamins and minerals are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Aimovig 70-milligrams/milliliter Auto-Injector. 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 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.Aimovig is a biological brand drug on Tier 3 of the plans formulary. There are no biological brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the request and determined that the drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone 10-milligram tablet prescribed with a quantity of 336 tablets every 28 days to treat chronic lower back pain in an enrollee with a lumbar spine tumor. 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 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 plan limits the amount of Oxycodone 10-milligram tablet to 180 tablets every 30 days. The prescriber indicates they prescribed Oxycodone 10-milligram tablets 3 tablets every 6 hours as needed for chronic pain and the enrollee is stable on the amount prescribed. The documentation does not support the plans quantity limit would be ineffective or would likely cause harm. Therefore, an exception to the plans coverage criteria is not supported. A physician reviewed the appeal and determined that the requested quantity of the drug at issue is not eligible for Part D coverage.