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

At issue is a tiering exception request for Januvia 100 milligram tablet to treat the enrollee's condition.. 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. Januvia 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 a tiering exception request for Eliquis 2.5 milligram tablet to treat the enrollee's condition. 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.Eliquis 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 Eliquis 5 milligram tablet to reduce the risk of stroke and systemic embolism associated with atrial fibrillation. 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 coverage for Aprepitant 40 milligram capsule to treat cannabinoid hyperemesis syndrome. 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 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 Xarelto 20 milligram tablets for prophylaxis against deep vein thrombosis. 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.Xarelto 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 Lidocaine 5 percent pain to treat pain associated with lumbar spinal stenosis. 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, pain etiology and history, 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 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 Aranesp 60 microgram per 0.3 milliliter prefilled syringe to treat anemia associated with chronic kidney disease. The Part D plan denied the request for coverage stating that the drug would be available for coverage under Medicare Part B, as the enrollee was currently receiving dialysis. 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 also researched Medicare systems and reviewed the enrollment data available. The documentation submitted at reconsideration clarifies that the enrollee is not currently receiving dialysis. In addition, Medicare systems validate that the enrollee does not currently have end stage renal disease coverage and is not currently receiving dialysis. Therefore, the drug would not be available for coverage under Medicare Part B. However, Aranesp 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. During this review, we requested medical records and a prescriber statement to address the formulary alternative drugs to treat the enrollees condition. The prescriber did not respond to the request. As such, the formulary exception criteria have not been met.  Please note that Procrit is available on the plan's formulary.  Procrit has 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 Fentanyl 75 microgram per hour transdermal patch to treat pain associated with an abdominal wall abscess. 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 documentation submitted.The plan limits the amount of opioid-containing drugs the enrollee has on hand per day to 200 morphine milligram equivalents (MME). The available documentation supports the enrollee will have more than 200 MMEs on hand per day with the requested drug and the enrollees current drug regimen. During this review, a request was submitted to the prescriber to address the amount of MMEs of opioid the enrollee has on hand per day and to provide supporting medical records. The prescriber did not respond to the request. As such, an exception to the plans quantity limit 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 coverage for Lidocaine 5 percent patch to treat chronic back pain associated with degenerative disc 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 documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to clarify the condition being treated and to address the plans coverage requirements for the drug. The prescriber did not respond.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 Plegridy 125 microgram per 0.5 milliliter injection solution to treat relapsing-remitting multiple sclerosis. 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 the enrollee has satisfied the plans prior authorization coverage criteria. We received additional documentation and included it in the review.The documentation satisfies the plans coverage criteria. The submitted documentation supports the enrollee has a diagnosis of relapsing-remitting multiple sclerosis.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 Valtoco 10 milligram per 0.1 milliliter nasal spray to treat intermittent episodes of frequent seizure activity. 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 that must be met before coverage can be approved. The submitted documentation does not support that all of the plans requirements for coverage have 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 Cosentyx 150 milligram per milliliter injection solution to treat ankylosing spondylitis. 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 all formulary alternatives were tried and failed or were contraindicated. We received additional documentation and included it in the review.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 Shingrix vaccine prescribed for vaccination. The Part D plan auto-forwarded the case.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 enrollee was administered the requested drug for vaccination in the prescriber's office. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt or physician's statement showing the amount that was paid by the enrollee was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Rinvoq 15 milligram extended-release tablet to treat 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 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 that must be met before coverage can be approved. The submitted documentation does not support that all of the plans requirements for coverage have 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 Aprepitant 80 milligram capsule prescribed to treat nausea and vomiting due to chemotherapy. 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 submitted documentation indicates the requested drug is prescribed for the treatment of nausea and vomiting due to chemotherapy. The plan indicates approval has been authorized under Medicare Part B through May 21, 2025. Based on the information provided, we determined the drug is not eligible for Part D coverage under Medicare rules. Contact your Part B plan directly to learn more about how coverage will be provided.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benzonatate 200 milligram capsule to treat cough. 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.Drugs prescribed for the symptomatic treatment of cough and colds are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 50 milligram capsules to treat chronic pain secondary to an unspecified injury. 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.At reconsideration, a diagnosis of spinal cord injury was given. However, no documentation was provided by the prescriber to support this diagnosis. We are not able to determine whether the requested drug was prescribed for a medically accepted indication. Therefore, the 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 Jardiance 25 milligram tablet prescribed 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 enrollee is requesting reimbursement for the requested drug for date of fill November 2, 2021, based on a tier exception approval. However, the tier exception was not effective until December 27, 2021. Therefore, the plan provided claim information showing the enrollee was in the coverage gap stage when the claim was processed for reimbursement. The plan paid its share of the cost for the covered drug and the enrollee was responsible for their share of the remaining 25%. We determined that the plan calculated the enrollees cost share in the coverage gap stage for a tier 3 drug and no additional reimbursement is required.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tradjenta 5 milligram tablet prescribed 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 enrollee is requesting reimbursement for the requested drug for date of fill November 2, 2021, based on a tier exception approval. However, the tier exception was not effective until December 27, 2021. Therefore, the plan provided claim information showing the enrollee was in the coverage gap stage when the claim was processed for reimbursement. The plan paid its share of the cost for the covered drug and the enrollee was responsible for their share of the remaining 25%. We determined that the plan calculated the enrollees cost share in the coverage gap stage for a tier 3 drug and no additional reimbursement is required.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cinacalcet Hydrochloride 30 milligram tablets to treat hypercalcemia in patients with primary hyperparathyroidism. 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 Tetanus Diphtheria and Pertussis vaccine prescribed for vaccination. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The enrollee is requesting reimbursement for the vaccine obtained and administered in the physicians office. However, there is missing information needed to consider the request. The required information includes the prescribing physicians name, address and National Provider Identifier (NPI) number, a valid National Drug Code (NDC) for the vaccine and valid proof of payment in the form of a receipt or physician's statement showing the vaccine and administration fee was paid in full. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Temazepam 30 milligram capsule to treat insomnia. 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 Contour Next Test Strip prescribed for 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, including the case file from the plan, and any information submitted at the reconsideration level. Supplies for testing and monitoring blood glucose levels are not considered Part D drugs and may be covered under the Medicare Part B durable medical equipment benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cetirizine Hydrochloride 10 milligram tablet. 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.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.In addition, the plans Evidence of Coverage indicates that the supplemental benefit permits coverage for certain approved over-the-counter drugs or products, but only when these items are ordered online by mail order.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Naproxen-Esomeprazole 500-20 milligram delayed-release tablet prescribed to decrease the risk of developing gastric ulcers and for the treatment arthritis 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 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 that must be met before coverage can be approved. The submitted documentation does not confirm that all of the plans requirements for coverage have 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 Tymlos 3120 microgram per 1.56 milliliter pen injector to treat other osteoporosis without current pathological fracture in a male enrollee. 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: Favorable

At issue is Pimecrolimus 1 percent cream to treat pruritus. 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. At reconsideration, the prescriber submits medical records that support chronic periorbital itchiness that did not respond to high dose Benadryl or topical Eucerin cream. The documentation satisfies the plans coverage criteria. The enrollee has symptoms consistent with atopic dermatitis and the area affected is around the eyes.  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.