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

At issue is coverage for Cosentyx Unoready 300 milligram dose (150 milligram per milliliter) solution auto-injector to treat hidradenitis suppurativa. 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 available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is a medically accepted indication for the drug as outlined in the Food and Drug Administration (FDA) product label, available at drugs@FDA. Therefore, the drug is being prescribed for a medically accepted indication  The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements have not been met. 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 coverage for Xeljanz XR (extended release) 11 milligram tablet to treat rheumatoid arthritis. 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 available documentation.The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why all of the alternative drugs on the plans formulary to treat the enrollees condition are contraindicated. Additionally, the submitted documentation does not support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements have not been met. 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 coverage for Simponi 100 milligram per milliliter solution auto injector to treat relapsing polychondritis. 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 available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. 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 coverage for Ozempic 2 milligram per 0.75 milliliter pen injector to treat severe obesity. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The noted condition is an off-label use for the requested drug. 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 Lisinopril 10 milligram tablet prescribed to treat enrollee's condition. 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. Your hospital dispensed your prescription medication using a national drug code (NDC) that has been repackaged and is therefore not a covered benefit. Therefore, it is not eligible for coverage under Medicare Part D. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methocarbamol 750 milligram tablet prescribed on 6/18/2023, to treat enrollee's condition. 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. Your hospital dispensed your prescription medication using a national drug code (NDC) that has been repackaged and is therefore not a covered benefit. Therefore, it is not eligible for coverage under Medicare Part D. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Potassium Chloride 10 milliequivalent tablet prescribed to treat enrollee's condition. 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. Your hospital dispensed your prescription medication using a national drug code (NDC) that has been repackaged and is therefore not a covered benefit. Therefore, it is not eligible for coverage under Medicare Part D. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Ozempic 2 milligram pen, 8 milligrams per 3 milliliters prescribed for unknown diagnosis. The Part D plan approved your 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 plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged you. The record shows the plan paid its share of the cost for the Ozempic 2 milligram pen and the remaining amount was your copay for a tier 3 drug filled at a preferred pharmacy. 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 Diphenhydramine Hydrochloride 50 milligram per milliliter vial prescribed for autoimmune disease. 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 provided documentation showing the enrollee requested coverage for a compounded drug. However, the Universal Claim Form for a Compounded Medication is not provided listing each ingredient, dosage, and the National Drug Codes (NDCs). Therefore, we determined the plan is not required to cover the compounded drug. 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: Favorable

At issue is Heplisav B 20 microgram per 0.5 milliliter injection prescribed for Hepatitis B 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 record shows the enrollee received the Heplisav B vaccine and a receipt has been submitted. The plans Evidence of Coverage states that payment for vaccines is required up front from the enrollee when provided at an out of network pharmacy or provider's 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 plans formulary shows the drug is covered as a Tier 3 drug. Therefore, we determined that the plan is required to reimburse the enrollee for their share of the cost for the Heplisav B vaccine for date of service August 22, 2023.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Simvastatin 20 milligram tablet prescribed for the treatment of dyslipidemia. 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. The plan submitted documentation that shows the enrollee was in the initial coverage stage when the drug was purchased at a standard pharmacy. According to the plans Evidence of Coverage, the requested drug is a tier 1 drug with a copay of $45 for a 90-day supply in the initial coverage stage for standard pharmacy. The record shows the full price of the drug was less than the $45 copay amount. Therefore, the 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 Amlodipine Besylate 5 milligram tablet for treatment of 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 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.The record shows the enrollee received a 90-day supply of the requested drug on August 1, 2023. According to the plans Evidence of Coverage, limits and restrictions are placed on drugs that are refilled too soon. Therefore, the claim for fill date August 1, 2023, was rejected at point of sale for refill too soon, and the amount charged to the enrollee was an out-of-pocket expense. 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 Atenolol 100 milligram tablet for treatment of 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 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.The record shows the enrollee received a 90-day supply of the requested drug on August 1, 2023. According to the plans Evidence of Coverage, limits and restrictions are placed on drugs that are refilled too soon. Therefore, the claim for fill date August 1, 2023, was rejected at point of sale for refill too soon, and the amount charged to the enrollee was an out-of-pocket expense. 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 a request for reimbursement for Glucocard blood glucose test strips. The Part D plan denied the request and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.There is missing information needed to consider the request. The submitted documentation does not include a reimbursement claim form that lists the National Drug Code (NDC) for the requested drug/item and the prescribing physicians name, address, and National Provider Identifier (NPI) number. Additionally, the available documentation does not include proof of payment to confirm that payment was made for the drug/item. Therefore, the reimbursement requirements have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for lancets used for blood glucose testing. The Part D plan denied the request and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.There is missing information needed to consider the request. The submitted documentation does not include a reimbursement claim form that lists the National Drug Code (NDC) for the requested drug/item and the prescribing physicians name, address, and National Provider Identifier (NPI) number. Additionally, the available documentation does not include proof of payment to confirm that payment was made for the drug/item. Therefore, the reimbursement requirements have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Fentanyl 12 microgram per hour patch to treat chronic pain. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Fentanyl 12 microgram per hour patch is a generic drug on Tier 4 of the plans formulary. There are no generic drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is ADACEL (Pertussis Vaccine, Acellular/Reduced Diphtheria Toxoid and Tetanus Toxoid) vaccine 5-2-15.5 LF-micrograms per 0.5 milliliter suspension and administration fee 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 submitted documentation shows the enrollee was administered the requested drug for vaccination in the prescriber's office. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid by the enrollee, was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Menveo solution and the administration fee for date of service June 13, 2023, prescribed for vaccination. The Part D plan denied the request and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the enrollee received the meningococcal vaccine and a receipt has been submitted for both the vaccine and the administration fee for a total of $188.00 for service date June 13, 2023. The plans Evidence of Coverage states that payment for vaccines is required up front from the enrollee when provided at an out of network pharmacy or provider's office. If an enrollee pays the full cost of a prescription and administration fee, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The plans formulary shows the drug is covered as a Tier 3 drug. Therefore, we determined that the plan is required to reimburse the enrollee for their share of the cost for the Menveo solution and administration fee for date of service June 13, 2023.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Shingrix 0.5 milliliter injection 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 all available documentation.The submitted documentation shows the enrollee received the vaccine from a retail pharmacy. 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 enrollee provided a statement from the prescribers office and a cancelled check indicating full payment was made for the vaccine and administration fee. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alprazolam 1 milligram tablet prescribed for the enrollee's condition. The Part D plan auto-forwarded the case to us for review.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 enrollee filled a prescription for the requested drug at a network pharmacy. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Meclizine 25 milligram tablet prescribed for the enrollee's condition. The Part D plan auto-forwarded the case to us for review.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 enrollee filled a prescription for the requested drug at a network pharmacy. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Nucynta ER (extended release) 50 milligram tablet to treat low back pain associated with spinal stenosis and post laminectomy syndrome. The Part D plan denied the request for coverage and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.During this review, we requested medical records and a prescriber statement to support that all formulary alternative drugs to treat the enrollees condition 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. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale, with supporting medical records, as to why the alternative drugs on the plans formulary to treat the enrollees condition are contraindicated. Additionally, the submitted medical records do not confirm that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception criteria have not been met.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 coverage for Repatha Sureclick 140 milligram per milliliter injection solution to treat atherosclerotic cardiovascular disease and hyperlipidemia. 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 available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.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 Rocklatan 0.02-0.005 percent solution to treat open-angle glaucoma. 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 available documentation. Rocklatan 0.02-0.005 percent solution is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception.  A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Duloxetine 30 milligram tablet to treat chronic cough. 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 available documentation. 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. As such, a quantity limit exception determination is not feasible at this time. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.