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

At issue is Zolpidem 10 milligram tablet purchased on March 2, 2021 prescribed for unknown diagnosis. The Part D plan denied the reimbursement 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 submitted documentation shows the enrollee purchased drugs from a pharmacy outside of the United States. Drugs purchased outside of the United States are excluded from coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem 10 milligram tablet purchased on May 14, 2020 prescribed for unknown diagnosis. The Part D plan denied the reimbursement 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 submitted documentation shows the enrollee purchased drugs from a pharmacy outside of the United States. Drugs purchased outside of the United States are excluded from coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem 10 milligram tablet purchased on November 17, 2020 prescribed for unknown diagnosis. The Part D plan denied the reimbursement 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 submitted documentation shows the enrollee purchased drugs from a pharmacy outside of the United States. Drugs purchased outside of the United States are excluded from coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem 10 milligram tablet purchased on October 12, 2020 prescribed for unknown diagnosis. The Part D plan denied the reimbursement 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 submitted documentation shows the enrollee purchased drugs from a pharmacy outside of the United States. Drugs purchased outside of the United States are excluded from coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem 10 milligram tablet purchased on September 14, 2020 prescribed for unknown diagnosis. The Part D plan denied the reimbursement 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 submitted documentation shows the enrollee purchased drugs from a pharmacy outside of the United States. Drugs purchased outside of the United States are excluded from coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a direct member reimbursement request for 5-percent/5-percent FU compounded cream. 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 submitted documentation contains a receipt to support the enrollee has purchased the drug at issue. However, there were no medical records submitted to support a prescribed diagnosis. It cannot be determined the drug was prescribed for a medically accepted indication. 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 Methadone Hydrochloride 10-milligrams to treat chronic pain 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 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 Methadone Hydrochloride to 120 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 tiering exception request for Trelegy Ellipta 100-microgram/1-actuation-62.5-microgram/1-actuation-25-microgram/1-actuation. 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.Trelegy Ellipta 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 Budesonide 0.5-milligram/2-milliliter nebulizer ampules prescribed for chronic rhinosinusitis. 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 a request for coverage of Restasis 0.05 percent ophthalmic dropperettes prescribed for the treatment of dry eye 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 alternative drug provided on the plans formulary, Xiidra, would likely not be as effective for this diagnosis and/or would likely cause adverse reaction(s) or other harm. Therefore, the documentation does not support a formulary exception. It is noted that the enrollee has also requested a tiering exception for the Restasis. However, a tiering exception cannot be granted for a drug that is not covered by the plan.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 Desoximetasone Cream 0.25 percent to treat malignant neoplasm of left kidney, except renal pelvis. 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 Rivastigmine 4.6-milligrams per 24-hour patch to treat unspecified memory loss, cognitive change, and probable pseudodementia with depression. 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 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 these diagnoses. 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 Calcitriol 0.25-microgram capsules prescribed for secondary hyperparathyroidism associated with end stage renal disease with patient currently on dialysis. 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. According to Medicare rules, the requested drug is eligible for coverage under the Part B end stage renal disease payment bundle. Drugs which are eligible for Part B coverage are excluded from Part D coverage. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eysuvis 0.25 percent eye drops to treat dry eye 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.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 Imatinib Mesylate 400-milligram tablets prescribed for chronic myeloid leukemia, BCR/ABL-positive, not newly diagnosed. 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.We requested additional information from the prescriber. Specifically, we requested medical records to support a covered condition. However, we did not receive the requested documentation.The submitted documentation indicates the prescriber ordered the drug at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There are no Medicare-approved peer-reviewed journal articles to support the use of the drug for the enrollees condition. The enrollee is not newly diagnosed, has not failed interferon alpha therapy, and has previously been on a TKI treatment. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ubrelvy 50-milligram tablets prescribed for migraine, unspecified, not intractable, without status migrainosus. The Part D plan denied the request for a tiering exception.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.Ubrelvy is a brand drug on Tier 3 of the plans formulary. There are no other brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Nuedexta (dextromethorphan 20 milligrams with quinidine 10 milligrams) prescribed as directed for pseudobulbar affect. The Part D plan denied your 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Nuedexta to treat your pseudobulbar affect. FDA labeling indicates that your diagnosis is a medically accepted indication. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided indicates a diagnosis of Parkinsons disease and does show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Nuedexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ketoconazole 2 percent cream 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 submitted documentation shows UNA RX discount card was applied to the purchase of the requested drug. Medicare rules state that discount cards are intended for out-of-pocket paying consumers and may not be used in conjunction with Medicare. When the enrollees benefit card was used, the enrollee acknowledged and agreed that UNA RX 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mupirocin ointment 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 submitted documentation shows Medimpact DC PCN ASPROD1 was applied to the purchase of the requested drug. Medicare rules state that discount cards are intended for out-of-pocket paying consumers and may not be used in conjunction with Medicare. When the enrollees benefit card was used, the enrollee acknowledged and agreed that Medipact DC PCN ASPROD1 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Primidone 50 milligram tablet 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 submitted documentation shows UNA RX discount card was applied to the purchase of the requested drug. Medicare rules state that discount cards are intended for out-of-pocket paying consumers and may not be used in conjunction with Medicare. When the enrollees benefit card was used, the enrollee acknowledged and agreed that UNA RX 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Preservision Areds 2 capsule 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 submitted documentation shows the requested drug was purchased without a prescription. Therefore, the plan is not required to cover or provide reimbursement for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocodone-Acetaminophen 5-325 milligram tablet prescribed for unknown diagnosis. The Part D plan denied 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 self-administered drug while in a hospital outpatient stay. Medicare rules state that drug claims must include a valid National Drug Code that is listed with the Food and Drug Administration. The National Drug Code provided is for a repackaged drug that is not listed with the Food and Drug Administration as a valid code. According to the plan's Evidence of Coverage, a request for reimbursement must include proof of payment. In this case, proof of payment in the form of a receipt showing the amount that the enrollee paid was not provided. Therefore, we determined that the plan is not required to provide reimbursement at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone 5 milligram tablet prescribed for unknown diagnosis. The Part D plan denied 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 self-administered drug while in a hospital outpatient stay. Medicare rules state that drug claims must include a valid National Drug Code that is listed with the Food and Drug Administration. The National Drug Code provided is for a repackaged drug that is not listed with the Food and Drug Administration as a valid code. According to the plan's Evidence of Coverage, a request for reimbursement must include proof of payment. In this case, proof of payment in the form of a receipt showing the amount that the enrollee paid was not provided. Therefore, we determined that the plan is not required to provide reimbursement at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sucralfate 100 milligram/milliliter suspension prescribed for unknown diagnosis. The Part D plan denied 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 self-administered drug while in a hospital outpatient stay. Medicare rules state that drug claims must include a valid National Drug Code that is listed with the Food and Drug Administration. The National Drug Code provided is for a repackaged drug that is not listed with the Food and Drug Administration as a valid code. According to the plan's Evidence of Coverage, a request for reimbursement must include proof of payment. In this case, proof of payment in the form of a receipt showing the amount that the enrollee paid was not provided. Therefore, we determined that the plan is not required to provide reimbursement at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sandostatin Lar Depot Kit 30 milligram prescribed as directed for neuroendocrine tumor. The Part D plan denied your 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. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. . However, we did not receive the documentation.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 medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Sandostatin Lar Depot Kit.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Dantrolene Sodium 25-milligram capsule to treat chronic spastic tetraplegia. 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.