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

At issue is Dulera 200/5-microgram HFA inhalation aerosol 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 alternative drugs provided on the plans formulary list 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 Bosentan 62.5 milligram tablet to treat Raynauds 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 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 Remicade for solution 100-milligram to treat Crohns 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 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 Taltz 80-milligram per milliliter injection to treat ankylosing spondylitis. 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 Mycophenolate Mofetil 500-milligram tablet to treat systemic involvement of connective tissue, 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 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 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 condition. 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 Vaqta 50 unit/milliliter suspension prescribed for vaccination. 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 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 submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the vaccine was administered. The plans Evidence of Coverage states that the 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 reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hyoscyamine Sulfate 0.125 milligram orally dissolving tablet. The Part D Plan denied the request We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The record shows the Hyoscyamine Sulfate is identified as a less than effective Drug Efficacy Study Implementation drug on the Medicare website.We determined that the plan is not required to cover Hyoscyamine Sulfate. Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. If you purchase drugs that are excluded, you must pay for them out-of-pocket. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ofev 150-milligram Capsule to treat idiopathic pulmonary fibrosis and interstitial lung 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation provided addressed the plans coverage criteria, and those criteria were not 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 Lidocaine 2 percent gel to treat catheter pain. 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 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 this formulation 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 Lidocaine 5-percent Patch to treat severe back pain 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 read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We asked your prescriber to send us a prescriber statement, a medically accepted indication (diagnosis), answers to prior authorization coverage criteria and pain history, and medical records. However, we did not receive the documentation.Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's 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 Levemir 100 unit/milliliter flex touch subcutaneous solution pen-injector to treat diabetes mellitus type 1. 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.Levemir is a biologic drug on Tier 3 of the plans formulary. There are no biologic 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: Favorable

At issue is Ajovy 225-milligrams/1.5-milliliter autoinjector for chronic migraine prophylaxis. 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. The prescriber provided patient specific clinical rationale supported by documentation, indicating why the formulary alternatives, required by the plan, would likely not be as effective as the requested drug for this diagnosis, and/or would likely cause adverse reaction(s) or other harm. 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 a tiering exception request for Ergotamine Tartrate-Caffeine 1-100-milligram to treat migraines. 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.Ergotamine Tartrate-Caffeine is a generic drug on Tier #3 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Diltiazem 120-milligram capsules with the purchase date of March 9, 2021, to treat an unknown diagnosis. The Part D plan denied the appeal 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 reimbursement request is for Diltiazem 120-milligram capsules. The documentation provided for review fails to include a valid National Drug Code for the requested product. The National Drug Codes should be provided to verify with the Food and Drug Administration. Therefore, we have determined that the plan is not required to cover and/or provide reimbursement for the requested drug with the purchase date noted above.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Finasteride 5-milligram tablets with the purchase date of March 10, 2021, to treat an unknown diagnosis. The Part D plan denied the appeal 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 reimbursement request is for Finasteride 5-milligram tablets. The documentation provided for review fails to include a valid National Drug Code for the requested product. The National Drug Codes should be provided to verify with the Food and Drug Administration. Therefore, we have determined that the plan is not required to cover and/or provide reimbursement for the requested drug with the purchase date noted above.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Losartan Potassium 50-milligram tablets with the purchase dates of March 9, and 10, 2021, to treat an unknown diagnosis. The Part D plan denied the appeal 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 reimbursement request is for Losartan Potassium 50-milligram tablets. The documentation provided for review fails to include a valid National Drug Code for the requested product. The National Drug Codes should be provided to verify with the Food and Drug Administration. Therefore, we have determined that the plan is not required to cover and/or provide reimbursement for the requested drug with the purchase dates noted above.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tukysa 150-milligram tablet to treat metastatic non small cell lung cancer, HER2 positive. 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. Medicare-approved compendia do not contain any citations to support the use of the requested drug as prescribed, for treatment of the noted diagnosis. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.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 Shingrix vaccination. 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 receipt to support the enrollee paid for the vaccination at issue. Therefore, the request for reimbursement cannot be granted.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Prograf 1-milligram capsule to treat an enrollee that is status post a heart transplant. 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: Unfavorable

At issue is Venclexta Starting Pack to treat marginal zone lymphoma. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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. Medicare-approved compendia do not contain any citations to support the use of the requested drug as prescribed, for treatment of the noted diagnosis. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.As such, an exception request, based on medical necessity, cannot be considered because the drug as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the drug is not eligible for coverage under Medicare Part D for the noted diagnosis.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 Zaleplon 5-milligram capsules 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 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 medical records and a prescriber statement to support all formulary alternatives were tried and failed or were contraindicated. We received additional documentation and included it in the review.The requested drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation from the prescriber does not support why all alternative drugs provided on the plans formulary list 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 Zoster 0.5 milliliter vaccine injection prescribed for vaccination. 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 physicians office. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or prescribers office. 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 documentation submitted includes a statement from the physicians office and a credit card receipt from the enrollee. Therefore, we determined that the plan is required to reimburse the enrollee for their share of the cost for the vaccine and administration fee.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Afinitor 10 milligram tablet to treat uterine carcinosarcoma. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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. Medicare-approved compendia do not contain any citations to support the use of the requested drug as prescribed, for treatment of the noted diagnosis. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.As such, an exception request, based on medical necessity, cannot be considered because the drug as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the drug is not eligible for coverage under Medicare Part D for the noted diagnosis.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 Cefazolin 1 gram injection prescribed daily for unknown 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 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 submitted documentation that shows the enrollee was in the initial coverage stage of the Part D benefit when this drug was purchased. According to the plans Evidence of Coverage, Cefazolin is a tier 4 drug with a copay of $95, in the initial coverage stage. The record shows the full price of the drug was less than the $95 copay amount. Therefore, the enrollees charge was based on the total cost of the drug. 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 Vanicream-Gabapentin compound drug prescribed for unknown 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 your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the Gabapentin powder has not been approved by the Food and Drug Administration for both safety and effectiveness. The Vanicream is an over-the-counter product and not eligible for coverage under Part D. Therefore, the requested compound does not meet the definition of Part D drug and is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Arnuity Ellipta 200 microgram inhaler prescribed to the enrollee during an outpatient emergency room visit. The Part D plan denied the request.We requested the case to perform an independent and de novo review. To make our decision, we reviewed the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation includes a reimbursement request form and hospital receipt for the requested drug. However, the plan provided information indicating the National Drug Code for the requested drug was either missing or not valid. Medicare rules state that drug claims must include a valid National Drug Code that is listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to reimburse the enrollee at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol Sulfate 2.5 milligram/3 milliliter vial 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. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover the requested drug.