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

At issue is Tramadol 50 milligram tablet prescribed to treat an unspecified diagnosis. 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 requested the Part D plan to provide reimbursement for the requested drug provided while in an outpatient hospital stay. However, there is missing information needed to consider the request. The submitted documentation does not include the prescribing physicians name, address and National Provider Identifier (NPI) number and the National Drug Code (NDC) of the requested drug. Therefore, we determined the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Asmanex Twisthaler 220 milligram to treat asthma. 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 Testosterone 1 percent gel packet to treat other specified abnormal findings of blood chemistry. 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 Dupixent 300 milligram per 2 milliliter injector to treat severe asthma. 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: Favorable

At issue is Epclusa 400/100 milligram tablet to treat chronic hepatitis C, genotypes 1 and 2, decompensated liver disease in a patient that cannot use Ribavirin. 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 a medically indicated use. The Medicare approved compendia contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Additional information regarding the diagnosis, prior treatment, genotypes and the presence of decompensated liver disease, were provided at reconsideration. Therefore, the requested drug(s) is eligible for coverage under Medicare Part D. 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 Siliq 210 milligrams per 1.5 milliliter syringe to treat plaque psoriasis. 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 a tiering exception request for Bydureon BCise 2 milligram per 0.85 milliliters auto injector to treat type 2 diabetes mellitus with hyperglycemia. 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. Bydureon BCise 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 Estradiol powder, Glycerin liquid, HRT Heavy cream 1 gram prescribed for 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.Medicare rules state, that bulk powders for pharmaceutical compounding do not satisfy the definition of a Part D drug and are not covered by Part D. In addition, over the counter drugs are excluded from coverage under Medicare Part D. The requested compounded drug includes both bulk powder ingredients and over the counter ingredients and is therefore, excluded from coverage and not eligible for reimbursement. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexletol 180 milligram tablet to treat hyperlipidemia, 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.The use of the requested drug to treat the provided diagnoses are off-label uses. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these diagnoses. 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 Edarbi 40 milligram tablet to treat hypertension. 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 Cresemba 186 milligram capsule to treat myelodysplastic 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 use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Sutab 1479-225-188 milligram tablet prescribed for colonoscopy preparation. 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.Sutab is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower tiers of the plans formulary. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewer determined that tiering exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bies (Estradiol, Estriol) 1 milligram/gram Versabase cream prescribed to treat osteopenia. 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.Drugs that are not approved by the Food and Drug Administration (FDA) are excluded from coverage under Medicare Part D. The National Drug Code (NDC) for each of the individual ingredients within the requested compound drug is not listed with the FDA. Therefore, the compound drug is excluded from coverage under Part D and not eligible for reimbursement. This decision does not address the medical necessity or appropriateness of the drug/product. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocortisone Acetate 25 milligram suppository. 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 that are available Over the Counter 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 coverage for Actemra 162 milligram per 0.9 milliliter prefilled subcutaneous injection syringe to treat polymyalgia rheumatica. 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.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 Euflexxa 20 milligram per 2 milliliter prefilled syringe to treat osteoarthritis of both knees. 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. Euflexxa is an injectable that is approved by the Food and Drug Administration as a medical device that relieves the pain of knee or hip osteoarthritis. Since this is considered a device, it is not eligible for Part D benefits. We have determined that the plan is not required to cover Euflexxa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acetaminophen 500 milligram tablet prescribed to treat an unspecified diagnosis. 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 requested the Part D plan to provide reimbursement for the Docusate Sodium given as a self administered drug while in an outpatient hospital stay. However, there is missing information needed to consider the request. The required information includes the National Drug Code (NDC) of the requested drug and the prescribing physicians name, address and National Provider Identifier (NPI) number. The enrollee provided a hospital statement including the amount charged for the self-administered drug and proof of payment. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aspirin 81 milligram tablet prescribed to treat an unspecified diagnosis. 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 requested the Part D plan to provide reimbursement for the Docusate Sodium given as a self administered drug while in an outpatient hospital stay. However, there is missing information needed to consider the request. The required information includes the National Drug Code (NDC) of the requested drug and the prescribing physicians name, address and National Provider Identifier (NPI) number. The enrollee provided a hospital statement including the amount charged for the self-administered drug and proof of payment. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bisacodyl 10 milligram suppository prescribed to treat an unspecified diagnosis. 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 requested the Part D plan to provide reimbursement for the Docusate Sodium given as a self administered drug while in an outpatient hospital stay. However, there is missing information needed to consider the request. The required information includes the National Drug Code (NDC) of the requested drug and the prescribing physicians name, address and National Provider Identifier (NPI) number. The enrollee provided a hospital statement including the amount charged for the self-administered drug and proof of payment. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Celecoxib 100 milligram capsule prescribed to treat an unspecified diagnosis. 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 requested the Part D plan to provide reimbursement for the Docusate Sodium given as a self administered drug while in an outpatient hospital stay. However, there is missing information needed to consider the request. The required information includes the National Drug Code (NDC) of the requested drug and the prescribing physicians name, address and National Provider Identifier (NPI) number. The enrollee provided a hospital statement including the amount charged for the self-administered drug and proof of payment. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine 10 milligram capsule prescribed to treat an unspecified diagnosis. 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 requested the Part D plan to provide reimbursement for the Docusate Sodium given as a self administered drug while in an outpatient hospital stay. However, there is missing information needed to consider the request. The required information includes the National Drug Code (NDC) of the requested drug and the prescribing physicians name, address and National Provider Identifier (NPI) number. The enrollee provided a hospital statement including the amount charged for the self-administered drug and proof of payment. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Docusate Sodium 100 milligram capsule prescribed to treat an unspecified diagnosis. 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 requested the Part D plan to provide reimbursement for the Docusate Sodium given as a self administered drug while in an outpatient hospital stay. However, there is missing information needed to consider the request. The required information includes the National Drug Code (NDC) of the requested drug and the prescribing physicians name, address and National Provider Identifier (NPI) number. The enrollee provided a hospital statement including the amount charged for the self-administered drug and proof of payment. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gemfibrozil 60 milligram tablet prescribed to treat an unspecified diagnosis. 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 requested the Part D plan to provide reimbursement for the Docusate Sodium given as a self administered drug while in an outpatient hospital stay. However, there is missing information needed to consider the request. The required information includes the National Drug Code (NDC) of the requested drug and the prescribing physicians name, address and National Provider Identifier (NPI) number. The enrollee provided a hospital statement including the amount charged for the self-administered drug and proof of payment. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mineral oil 30 liquid prescribed to treat an unspecified diagnosis. 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 requested the Part D plan to provide reimbursement for the Docusate Sodium given as a self administered drug while in an outpatient hospital stay. However, there is missing information needed to consider the request. The required information includes the National Drug Code (NDC) of the requested drug and the prescribing physicians name, address and National Provider Identifier (NPI) number. The enrollee provided a hospital statement including the amount charged for the self-administered drug and proof of payment. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tramadol Hydrochoride 50 milligram tablet prescribed to treat an unspecified diagnosis. 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 requested the Part D plan to provide reimbursement for the Docusate Sodium given as a self administered drug while in an outpatient hospital stay. However, there is missing information needed to consider the request. The required information includes the National Drug Code (NDC) of the requested drug and the prescribing physicians name, address and National Provider Identifier (NPI) number. The enrollee provided a hospital statement including the amount charged for the self-administered drug and proof of payment. However, the amount of payment by the enrollee is less than the total amount charged for the self-administered drugs. Therefore, reimbursement amounts cannot be determined and criteria have not been met.