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

At issue is Clotrimazole 1-perent solution to treat fungal otitis externa. 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 drug at issue is not on the plans formulary. Clotrimazole solution has an orphan drug designation in Micromedex for this condition. The formulary alternatives do not have a medically accepted indication for the use in fungal otitis externa. Use of creams and powders are not appropriate for patient application for this indication in the ear canal. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ure-Na 15-gram packet to treat hyponatremia. 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 use as vitamins and minerals 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 Sterile Water for injection used in a compounded drug prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the Sterile Water is used within a compounded drug for injection. The Food and Drug Administration (FDA) lists this drug as excluded from coverage under Medicare Part D. Therefore, it does not meet the definition of a Part D drug and is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide 0.5 milligram per 2 milliliter ampul for nebulizer prescribed for the treatment of asthma. 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 the requested drug is being administered through a nebulizer in the home setting. Therefore, we determined the drug may be eligible for coverage under Part B under Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is FreeStyle Libre 14 day Reader Device prescribed for 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. Supplies for testing and monitoring blood glucose levels are not considered Part D drugs and may be covered under the Medicare Part B durable medical equipment benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fentanyl 100-microgram/72-hour patch to treat pain severe enough to require daily,around-the-clock, long-term opioid treatment. 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 ReliOn Novolin N 100 units per milliliter vial. The case was auto-forwarded by the plan.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 Azathioprine 50 milligram tablet to treat polyarteritis nodosa. 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 Fluzone High-Dose Quad 0.7 milliliter suspension prefilled syringe. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the requested vaccine at their prescribers office. Based on the information provided, we determined the drug may be eligible for coverage under Medicare Part B. A drug that is covered under Part B is not eligible for coverage under Part D. Therefore, the Part D plan is not required to cover or provide reimbursement for the requested vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluzone High-Dose Quad 240 microgram per 0.7 milliliter vaccine. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the requested vaccine at their prescribers office. Based on the information provided, we determined the drug may be eligible for coverage under Medicare Part B. A drug that is covered under Part B is not eligible for coverage under Part D. Therefore, the Part D plan is not required to cover or provide reimbursement for the requested vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gralise 600 milligram tablet to treat unspecified polyneuropathy. 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.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 Boostrix 0.5 milliliter suspension prefilled syringe prescribed for vaccination. 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 plan submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the vaccine was administered at the pharmacy. The plans Evidence of Coverage states that enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined the amount the enrollee paid was applied to the deductible and no additional reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Febuxostat 40-milligram tablet. 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 being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception. A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Mekinst 2 milligram tablet to treat serous ovarian cancer. 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 documentation indicates the enrollee has had chemotherapy, Tamoxifen and Letrozole. While on Letrozole, there was progression and the prescriber would like to add Mekinist. While on Tamoxifen, enrollee developed breast cancer that was hormone positive and so Letrozole was added at that time with secondary benefit to the ovarian cancer. The National Comprehensive Cancer Network (NCCN) and The American Hospital Formulary Service Drug Information (AHFS DI) both support the use of Mekinist. NCCN states it can be used as a single agent therapy for platinum-sensitive or platinum-resistant recurrence (NCCN 2A) and AHFS DI states that it can be used in those who have received one prior therapy (Lexicomp evidence, off-label category B) for ovarian carcinoma. Mekinst is supported per compendia for treatment of ovarian carcinoma, the drug is on the plans formulary, and the prior authorization criteria is consistent with Food and Drug Administration guidelines which are met. 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 Modafinil 100 milligram tablet to treat obstructive sleep apnea syndrome and daytime somnolence. 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 coverage criteria that must be met prior to approval. The criteria indicates the enrollee must have a Food and Drug Administration approved indication. The Medicare approved compendia contain a citation to support the use of the drug for the enrollees noted diagnosis. Therefore, an exception to the plans coverage criteria is medically necessary. A request was submitted to the prescriber to address all formulary alternatives were tried and failed or were contraindicated. However, we did not receive the requested information. 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 Tramadol extended release 300-milligram tablets to treat around the clock pain associated with chronic neck, low back and joint pain with cervical disc disease, cervical spondylosis, cervical spinal stenosis, C5-C6 fusion, lumbar disc disease with radiculopathy, lumbar spondylosis, L5-S1 fusion, osteoarthritis bilateral knees, right meniscus repair, right tarsal tunnel, plantar fasciitis, bilateral posterior tibial tendinosis, left knee replacement, right knee replacement, left cubital tunnel and ulnar nerve transposition, fibromyalgia, Lupus, myofascial pain, pelvic asymmetry and gait derangement. 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 documentation satisfies the plans coverage criteria. A highly detailed medical record of May 3, 2022, was received that substantially satisfied the prior authorization criteria for this drug. 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 Albuterol HFA 90-microgram inhaler to treat your 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. 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 Metoprolol Succinate 50 milligram 24 hour extended release tablet prescribed for unspecified 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 the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale. The plans 2022 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment amount, and minus the difference between what the plan approves 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 Xarelto 20 milligram tablet prescribed for unspecified diagnosis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the requested drug was purchased. The plans 2022 Evidence of Coverage shows the enrollee is responsible for the full cost of covered drugs until the $480 deductible is met. The documentation indicates the enrollee's cost included the deductible of $480 and a copay of $106 for the tier 3 drug in the initial coverage stage. Therefore, we determined the calculation of deductible and copay was correct and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for the Tetanus Diphtheria and Pertussis (TDAP) vaccine prescribed for vaccination. The Part D plan auto-forwarded the request.We requested 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 proof of payment for the vaccine. However, Medicare rules state that drug claims must include a valid National Drug Code (NDC) that is listed with the Food and Drug Administration (FDA) and a valid National Provider Identifier (NPI) number for the prescriber. The documentation does not include a NDC for the vaccine or the prescribers NPI. Therefore, we determined that the plan is not required to reimburse the enrollee for the vaccine and administration fee at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Folic Acid 1 milligram tablet to treat arthropathic psoriasis, 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.Drugs prescribed for use as vitamins and minerals 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 Prevymis 480 milligram tablet for prophylaxis against cytomegalovirus infection for a bilateral lung transplant recipient with a history of cytomegalovirus viremia. 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.  In the reconsideration appeal the prescriber send a statement and supporting medical records.   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 Zolpidem Tartrate 10 milligram tablet 135 tablets per 90 days to treat insomnia. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we 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 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. The plan limits the amount of Zolpidem Tartrate to 30 tablets per 30 days. 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. Therefore, an exception to the plans coverage criteria is not supported.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Ketorolac tromethamine 0.5 percent solution. The Part D plan denied the request.We received a 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 does not include a valid proof of purchase for the drug at issue. There is no documentation to link the prescription numbers on the receipt to the drug at issue. Therefore, the request for reimbursement cannot be granted.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Ofloxacin 0.3 percent solution. The Part D plan denied the request.We received a 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 does not include a valid proof of purchase for the drug at issue. There is no documentation to link the prescription numbers on the receipt to the drug at issue. Therefore, the request for reimbursement cannot be granted.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Prednisolone acetate 1 percent suspension. The Part D plan denied the request.We received a 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 does not include a valid proof of purchase for the drug at issue. There is no documentation to link the prescription numbers on the receipt to the drug at issue. Therefore, the request for reimbursement cannot be granted.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Protonix 40 milligram tablet to treat gastroesophageal reflux disease. 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 Rasagiline Mesylate 1 milligram tablet to treat idiopathic Parkinson's disease. 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.