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

At issue is coverage for Lynparza 150 milligram tablet, 120 tablets per 30 days, to treat adenocarcinoma of liver of uncertain origin with BRCA 2 mutation. 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 submitted documentation indicates that the enrollee has a history of ovarian cancer that was treated in 2000 with chemotherapy and surgery. The documentation shows that in 2005, the enrollee had a recurrence of the ovarian cancer that was treated with chemotherapy again. The medical records show that the enrollee was found to have had stage 4 squamous cell cancer of lung in 2020, which was treated with chemotherapy/immunotherapy. The documentation indicates the enrollee now has new liver lesions in which the pathology shows pancreaticobiliary primary; however, metastatic ovarian cancer cannot be ruled out. As such, the documentation verifies that the enrollee has been on two to three lines of treatment for ovarian cancer. The documentation shows that enrollee will now be using Lynparza as monotherapy. As outlined in the National Comprehensive Cancer Network (NCCN) guidelines, it is a 2A recommendation to use Lynparza as single-agent therapy for persistent disease or recurrence in patients with deleterious germline BRCA mutation who have been treated with two or more lines of chemotherapy. In this case, enrollee has been on two lines of treatment for ovarian cancer and the pathology of liver biopsy cannot rule out ovarian cancer. With enrollee's unique history of multiple cancers and due to the fact that ovarian cancer recurrence cannot be ruled out, the enrollee does fit NCCN criteria. As such, the drug is being prescribed for a medically accepted indication as outlined in the NCCN guidelines.As outlined in the plans prior authorization requirements for the requested drug, the enrollee must have been previously treated with three lines of chemotherapy. The enrollee meets this requirement as the enrollee has been on three lines of treatment (the treatment the enrollee received for lung cancer is also effective against ovarian cancer). Therefore, the enrollee fits both NCCN guidelines and the plans prior authorization requirements to be treated with this medication. 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 Ethacrynic Acid 25 milligram tablet to treat edema associated with chronic kidney 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.The requested drug is not on the plans formulary. To grant an exception for a drug not that is not on the plans formulary, alternative formulary drugs must have been tried and failed, or deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why each formulary alternative drug listed by the plan would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Therefore, the formulary exception criteria 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 Diclofenac Sodium 1 percent gel to treat low back pain in an enrollee with scoliosis and arthritis. 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 Norpace 100 milligram tablets. The case was auto-forwarded by the plan.We received the submitted documentation to perform an independent and de novo review.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to clarify the medical history and to support all formulary alternatives were tried and failed or were contraindicated. However, we did not receive the requested information.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was 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 Ketoconazole 200 milligram tablet to treat tinea versicolor. 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 documentation submitted.The Part D plan has prior authorization requirements that have to be met before coverage of this drug is approved. The submitted documentation does not confirm that all of the plans coverage requirements have been met. During this review, a request was submitted to the prescriber to address the plans coverage requirements for the requested drug and to provide supporting medical records. The prescriber did not respond to the request. As such, there is insufficient documentation to support that the plans prior authorization criteria 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 coverage for Repatha 140 milligram per milliliter syringe. The Part D plan denied the request for coverage because the provided diagnosis of intolerance to statin drugs was not a medically accepted indication for the drug.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 clarified that the requested drug has been prescribed for myocardial infarction prophylaxis, stroke prophylaxis, and/or coronary revascularization prophylaxis in an enrollee with established cardiovascular disease. This is a medically accepted indication for the drug outlined in the Medicare approved compendia. However, the plan has prior authorization requirements for this drug that must be met before coverage is approved and/or renewed. While the prescriber has answered the prior authorization requirement questions submitted by the plan, no medical records have been submitted to confirm that the requirements have been satisfied. During this review, a request was submitted to the prescriber to address the plans coverage requirements for the requested drug and to provide supporting medical records to validate that these requirements have been met. The prescriber did not respond to the request. As such, there is insufficient documentation to support that all of the plans prior authorization criteria 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 Ozempic 8 milligrams per 3 milliliters injection to treat the enrollees 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.We requested additional information from the prescriber. Specifically, we requested a medically accepted indication, medical records, and a prescriber statement to support that all formulary alternatives were tried and failed or were contraindicated. We received additional documentation and included it in the review.At reconsideration, a diagnosis of type 2 diabetes mellitus with hyperglycemia was given. 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: Favorable

At issue is Tetanus Diphtheria and Pertussis (TDAP) vaccine prescribed for vaccination. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the vaccine at the prescriber's office. The plans Evidence of Coverage states that if an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The submitted information includes a receipt from the prescriber's office indicating full payment was made for the vaccine and administration fee. Therefore, we determined the plan is required to provide reimbursement based on the enrollee's cost share stage on the date of vaccination.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Tremfya 100 milligram per milliliter auto-injection pen to treat plaque psoriasis. The Part D plan denied the request for coverage because the drug was not on the formulary and the documentation did not support a formulary 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.While the plan denied the request for coverage stating that the drug was not on the plans formulary, Tremfya is included in the plans formulary. Additionally, the plan has prior authorization requirements for this drug. During this review, a request was submitted to the prescriber to address the plans coverage requirements for this drug and to provide supporting medical records. We received additional documentation and included it in the review.The plan has prior authorization requirements that need to be met before the drug 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 coverage for Zolpidem Tartrate 5 milligram tablet to treat insomnia. 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.During this review, a request was submitted to the prescriber to address the plans coverage requirements for this drug and to provide supporting medical records. We received additional documentation and included it in the review.The plan has prior authorization requirements that need to be met before the drug 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 Cyclobenzaprine 10 milligram tablet to treat chronic thoracic back pain. 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 20 milligram tablet prescribed for an 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill due to being incarcerated. Therefore, we determined the enrollee is responsible for the additional cost of the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Comfort EZ 33 gauge 6 millimeter pen needle prescribed for an 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill due to being incarcerated. Therefore, we determined the enrollee is responsible for the additional cost of the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 1 percent gel prescribed for an 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill due to being incarcerated. Therefore, we determined the enrollee is responsible for the additional cost of the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lantus Solostar 100 unit per milliliter solution prescribed for an 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill due to being incarcerated. Therefore, we determined the enrollee is responsible for the additional cost of the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levofloxacin 500 milligram tablet prescribed for an 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill due to being incarcerated. Therefore, we determined the enrollee is responsible for the additional cost of the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Losartan Potassium 500 milligram tablet prescribed for an 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill due to being incarcerated. Therefore, we determined the enrollee is responsible for the additional cost of the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metformin Hydrochloride 500 milligram tablet prescribed for an 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill due to being incarcerated. Therefore, we determined the enrollee is responsible for the additional cost of the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omeprazole delayed release 40 milligram capsule prescribed for an 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill due to being incarcerated. Therefore, we determined the enrollee is responsible for the additional cost of the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Potassium Chloride extended release 10 milliequivalent tablet prescribed for an 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill due to being incarcerated. Therefore, we determined the enrollee is responsible for the additional cost of the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Symbicort 160-4.5 microgram inhaler prescribed for an 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill due to being incarcerated. Therefore, we determined the enrollee is responsible for the additional cost of the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tradjenta 5 milligram tablet prescribed for an 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill due to being incarcerated. Therefore, we determined the enrollee is responsible for the additional cost of the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ventolin Hydrofluoroalkane (HFA) 90 microgram inhaler prescribed for an 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill due to being incarcerated. Therefore, we determined the enrollee is responsible for the additional cost of the drug.