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

At issue is Hydroxychloroquine 200 milligram tablet prescribed for amyopathic dermatomyositis. 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 is not eligible for coverage under Medicare Part D. This decision does not speak to the medical necessity of this drug; it speaks to whether the Part D drug plan is responsible for payment under the Centers for Medicare and Medicaid Services (CMS) rules. 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 Calcipotriene 0.005 percent cream to treat post-inflammatory hyperpigmentation. 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 cosmetic purposes 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 Amlodipine 10 milligram tablet for the date of purchase May 8, 2022, prescribed for unknown diagnosis. The Part D plan denied the 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 record shows the enrollee requested the plan to provide reimbursement for the requested drug. However, Medicare records indicate that the enrollee was not enrolled with the Part D plan for the dates of service requested. Therefore, we determined that the plan is not required to provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amlodipine 10 milligram tablet purchased on February 3, 2022, prescribed for unknown diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 claim for Amlodipine tablet for the date February 3, 2022, was approved and any copayment was charged correctly to the enrollee at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amlodipine 5 milligram tablet purchased on December 28, 2021, prescribed for unknown diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 claim for Amlodipine tablet for the date December 28, 2021, was approved and any copayment was charged correctly to the enrollee at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Atorvastatin 40 milligram tablets for the date of purchase March 24, 2022, prescribed for unknown diagnosis. The Part D plan denied the 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 record shows the enrollee requested the plan to provide reimbursement for the requested drug. However, Medicare records indicate that the enrollee was not enrolled with the Part D plan for the dates of service requested. Therefore, we determined that the plan is not required to provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Atorvastatin 40 milligram tablets purchased on December 28, 2021, February 23, 2022, and January 24, 2023, prescribed for unknown diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 claim for Atorvastatin tablets for the dates December 28, 2021, February 23, 2022, and January 24, 2023, was approved and any copayment was charged correctly to the enrollee at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clopidogrel 75 milligram tablet, purchased on December 28, 2021,prescribed for unknown diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 claim for Clopidogrel 75 milligram tablet for the date December 28, 2021, was approved and any copayment was charged correctly to the enrollee at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gabapentin 100 milligram capsule, purchased on January 13, 2022, prescribed for unknown diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 claim for Gabapentin 100 milligram capsule for the date January 13, 2022, was approved and any copayment was charged correctly to the enrollee at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lisinopril 20 milligram tablets for the date of purchase March 24, 2022 and April 24, 2022, prescribed for unknown diagnosis. The Part D plan denied the 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 record shows the enrollee requested the plan to provide reimbursement for the requested drug. However, Medicare records indicate that the enrollee was not enrolled with the Part D plan for the dates of service requested. Therefore, we determined that the plan is not required to provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lisinopril 20 milligram tablets, for purchased dates on December 28, 2021, January 24, 2022, June 1, 2022, and February 23, 2023, prescribed for unknown diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 claim for Lisinopril 20 milligram tablets for the dates December 28, 2021, January 24, 2022, June 1, 2022, and February 23, 2023, was approved and any copayment was charged correctly to the enrollee at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60 milligrams per milliliter to treat osteoporosis. The Part D plan denied the request for this quantity of medication. 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 plan limits the amount of this drug to 1 dose per 180 days. A request was submitted to the plan dated March 8, 2023, this was paid per the plan's records. A second request was submitted on March 23, 2023, this request has been denied. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the diagnosis or would be likely to cause harm. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage. Therefore, an exception to the plans coverage criteria is not supported.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Levemir Flexpen 100 units per milliliter insulin pen. 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 ca Se file from the plan, and any information submitted at the reconsideration level.This drug is on the lowest tier of the plans formulary and represents the lowest cost sharing level. A tiering exception cannot be made for this drug.A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic 0.25/0.5 milligrams per 0.5 milliliter solution in auto injector to promote weight loss. 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 to treat weight gain (promote weight loss) 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 Morphine Sulfate 15 milligram extended release tablet. The Part D plan denied the request. We received the submitted documentation to perform an independent and de novo review. 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 Albuterol sulfate HFA (hyrofluoroalkane) for an unstated 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, including the case file from the plan, and any information submitted at the reconsideration level. At reconsideration no diagnosis was provided. No medical records by the prescriber to support a diagnosis are present in the current record. This information was requested from the prescriber but no information was received. We are not able to determine whether the requested drug(s) 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 a tiering exception request for Jardiance 10 milligram tablets to treat type 2 diabetes. 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 a brand drug on Tier 3 of the plans formulary. The plan has indicated that this drug will be covered at that Tier level. There are no drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, it 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 Oxycontin 15 milligram extended release tablet to treat chronic 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 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 a tiering exception request for Movantik 12.5 milligram tablet to treat opioid induced constipation. 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.Movantik 12.5 milligram tablet is a brand drug on Tier 4 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 Dificid 200 milliligram tablet prescribed to treat diverticulitis. The Part D plan denied the 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 submitted documentation shows a discount card was applied to the purchase of the requested drug. Discount cards are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When the enrollees benefit card was used, the enrollee acknowledged and agreed that the Singlecare discount program will be treated as the primary payor with respect to the medications that are purchased through the discount program. Therefore, the plan is not required to cover or provide reimbursement for the requested drug. However, the plan indicates that the charge for this drug has been applied to the enrollee's true out of pocket (TROOP) costs.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic 2 milligrams per 1.5 milliliter for an unstated 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, including the case file from the plan, and any information submitted at the reconsideration level. At reconsideration no diagnosis was provided. No medical records by the prescriber to support a diagnosis are present in the current record. This information was requested from the prescriber but no information was received. We are not able to determine whether the requested drug(s) 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 Armour Thyroid (NP Thyroid) 120 milligram tablets. 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. According to the compendia, This drug has not been found by the FDA to be safe and effective, and the drug product labeling has not been approved by the FDA. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trulicity 1.5 milligram per 0.5 milliliter pen injector 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.Trulicity is a biologic on Tier 6 of the plans formulary. There are no lower tiers on the plans formulary. Therefore, this biologic 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 Ajovy 225 milligram per 1.5 milliliter syringe for the prevention of migraine headache. 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 Cevimeline Hydrochloride 30 milligram capsule to treat Sjogrens 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 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 Pregabalin 25 milligram capsule to treat headache, unspecified. 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 neuropathic pain due to 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(s) was prescribed for a medically accepted indication. Therefore, the 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 Capecitabine 500 milligram tablets to treat basal cell and squamous cell carcinomas. The Part D plan denied the request stating the drug was covered under Part B. 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 documentation indicates the prescriber ordered the drug at issue for the enrollees diagnosis. The Medicare approved compendia contain a citation to support the use of the drug for the noted diagnosis. As such, the submitted documentation supports the drug was prescribed for a medically accepted indication. The intravenous formulation of this oral cancer drug does not have the same medically accepted indication in the compendia; therefore, the drug at issue does not meet the criteria to be covered under Part B. The drug will be reviewed as a Part D drug.The drug at issue is not on the plans formulary. There are no other drugs on the plan's formulary to treat the enrollee's diagnosis. Therefore, an exception to the plans formulary coverage criteria is medically necessary.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.