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

At issue is Humira CF 40-milligram/0.4-milliliter pen injector prescribed for sarcoidosis. The Part D plan denied the request. We performed 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 submitted documentation indicates the prescriber ordered the biologic at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the biologic at issue for the enrollees condition. As the biologic was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lidocaine 5 percent patches. 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 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 documentation indicates that Lidocaine 5 percent patches have been prescribed for the treatment of upper back pain due to a recent closed fracture of the eleventh thoracic vertebrae. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gammaked 10-gram/100-milliliter intravenous solution prescribed for desensitization of highly sensitized patient prior to heart transplant. The Part D plan denied the request. We performed 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 submitted documentation indicates the prescriber ordered the biologic at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the biologic at issue for the enrollees condition. As the biologic was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol Sulfate 0.63-milligram/3-milliliter nebulizer solution prescribed for chronic obstructive pulmonary disease. The Part D plan denied the request. We performed 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 drug at issue is for use in a nebulizer in the enrollees home. This is eligible for coverage under Part B. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Tadalifil 20 milligram tablet. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication is needed. We did not receive the documentation requested. Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration approved, are excluded from coverage under Medicare Part D. Therefore, Tadalifil is excluded from coverage. Since the drug is not eligible for coverage under Part D, the plans tiering exception requirements are not applicable to this review. A physician reviewed the appeal and determined that the plan is not required to cover Tadalifil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Adacel(TDAP) vaccine prescribed for vaccination. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 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 showing the amount that was paid for the drug was not provided. Therefore, we determined that the plan is not required to provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Tobramycin Ophthalmic solution 15 milligram/milliliter drops prescribed to assist in the healing of a significant corneal ulcer. 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 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 drug at issue was dispensed at a pharmacy not in your plans network on the date the prescription was filled. In these instances, you may be responsible for paying the difference between what you pay for the drug at the out of network pharmacy and the cost that we would cover at an in network pharmacy. The documentation does not support an extreme emergency that would require the drug be immediately supplied and the drug could have been received from a network pharmacy.We determined that the plan is not required to reimburse you for Tobramycin Ophthalmic 15 milligram/milliliter drops.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Vancomycin Ophthalmic 25 milligram drop prescribed to assist in the healing of a significant corneal ulcer. 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 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 drug at issue was dispensed at a pharmacy not in your plans network on the date the prescription was filled. In these instances, you may be responsible for paying the difference between what you pay for the drug at the out of network pharmacy and the cost that we would cover at an in network pharmacy. The documentation does not support an extreme emergency that would require the drug be immediately supplied and the drug could have been received from a network pharmacy.We determined that the plan is not required to reimburse you for Vancomycin Ophthalmic 25 milligram drop.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Freestyle Libre glucose monitoring system prescribed for diabetes mellitus. The Part D plan denied the request. We performed 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 item at issue is not directly related to the administration of insulin. This is eligible for coverage under Part B. The plan does not offer supplemental (additional) coverage for this biologic. If the enrollee purchased biologics that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the biologic. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 10-milligram tablets prescribed for the enrollees condition. The Part D plan denied the request for a tiering exception.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.Jardiance is a brand drug on Tier 3 of the plans formulary. There are no other brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Entresto 24 milligram-26-milligram tablets prescribed for the treatment of dilated cardiomyopathy. Also at issue is a request for reimbursement for Entresto purchased on July 22, 2021, and July 26, 2021. The Part D plan denied the request for reimbursement and for a tiering exception.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. Entresto is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the enrollee's condition on the lower cost sharing tiers. 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 reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level. The drug will continued to be covered at a Tier 3 copay. Additionally, the amount paid for the drug on the dates noted above is not reimbursable.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement of $215.42 for Besivance 0.6 percent ophthalmic suspension eye drops for the date of service of July 16, 2021. The Part D plan denied the request for reimbursement.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 Part D plan has noted that the requested drug was denied coverage due to the prior authorization requirements not being satisfied. Please refer to the decision letter from the plan regarding the prior authorization denial for more details. Since the drug has been denied coverage, the plan is not required to reimburse the amount paid for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Flovent HFA 220 microgram aerosol with adaptor prescribed as directed to treat asthma. The Part D plan denied your request for a tiering exception.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. Flovent HFA 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 condition. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol Sulfate HFA 90 microgram inhaler prescribed for an unknown diagnosis. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 the enrollees claim for the Albuterol Sulfate and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan adjusted the copayment because Medicare records indicate the enrollee did not qualify for low income subsidy copay level beginning March 1, 2021. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the remaining copay. We have determined that the plan is correct in its recalculation of the enrollees copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Chantix continuing monthpak  prescribed for an unknown diagnosis. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 the enrollees claim for the Chantix and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan adjusted the copayment because Medicare records indicate the enrollee did not qualify for low income subsidy copay level beginning March 1, 2021. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the remaining copay. We have determined that the plan is correct in its recalculation of the enrollees copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epinephrine 0.3 milligram auto-injection prescribed for an unknown diagnosis. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 the enrollees claim for the Epinephrine and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan adjusted the copayment because Medicare records indicate the enrollee did not qualify for low income subsidy copay level beginning March 1, 2021. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the remaining copay. We have determined that the plan is correct in its recalculation of the enrollees copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Ellipta prescribed for an unknown diagnosis. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 the enrollees claim for the Trelegy Ellipta and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan adjusted the copayment because Medicare records indicate the enrollee did not qualify for low income subsidy copay level beginning March 1, 2021. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the remaining copay. We have determined that the plan is correct in its recalculation of the enrollees copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix 50 microgram/0.5 milliliter prescribed for an unknown diagnosis. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 the enrollees claim for the Shingrix and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan adjusted the copayment because Medicare records indicate the enrollee did not qualify for low income subsidy copay level beginning March 1, 2021. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the remaining copay. We have determined that the plan is correct in its recalculation of the enrollees copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested OneTouch Ultra test strips prescribed as directed. 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 record shows you requested coverage for OneTouch Ultra test strips. However, this product may be eligible for coverage under Medicare Part B. Medicare rules state drugs and medical supplies not directly associated with the injection of insulin are not covered under Part D. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.We determined that the plan is not required to cover OneTouch Ultra test strips.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pegasys 180 Microgram/milliliter injection prescribed for unknown diagnosis. The Part D plan denied the additional reimbursement 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 plan submitted documentation that shows the enrollee paid a copay of $204.12 at a net-work pharmacy for the requested drug on July 1, 2021. Additional information provided by the plan shows the claim was reversed by the pharmacy and ran again through the enrollees Part D plan on July 31, 2021, with a correct copay of $100. We determined that the plan calculated the copay correctly for the reversed claim, filed on July 31, 2021 by the enrollees pharmacy, and is not responsible for additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Wegovy 1.7 milligrams per 0.75 milliliters solution auto-injector prescribed to treat the diagnosis of obesity. The Part D plan denied the appeal request.The QIC 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 documentation shows the doctor prescribed Wegovy 1.7 milligrams per 0.75 milliliters solution auto-injector to treat obesity. We determined the plan is not required to cover Wegovy because it is excluded from coverage under Part D. 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

At issue is a request for coverage of Desvenlafaxine Succinate 50-milligram extended release 24-hour capsules. The Part D plan denied the request for coverage because there was insufficient documentation to determine if the plans prior authorization requirements met.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 submitted medical records indicate that Desvenlafaxine Succinate has been prescribed for the treatment of anxiety disorder. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. Since the drug is not eligible for coverage, the plans prior authorization requirements are not relevant to this review. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Humira 80-milligam per 0.8-milliliter subcutaneous injection pen. 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 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 documentation indicates that Humira has been prescribed for the treatment of dissecting cellulitis of the scalp and acne conglobata. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted conditions. Therefore, the drug is being prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D.  A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rytary ER 36.25-145 milligram capsule to treat Parkinsons disease. The Part D plan denied the request.  We performed 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 prescriber has provided patient specific clinical rationale and medical records. However, the documentation does not adequately address, with support in the medical record, why all alternatives required by the plan would likely not be as effective as Rytary; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.