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

At issue is Prolia 60 milligram per milliliter solution prefilled syringe to treat postmenopausal osteoporosis. 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 Methylphenidate Hydrochloride 20 milligram tablet, 120 per 30 days. 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 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 and a prescriber statement to support a covered diagnosis and that the quantity prescribed was medically necessary for the enrollee. However, we did not receive the requested information.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. Please note, this reconsideration decision was based on the plans 2023 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 Amlodipine Besylate 10 milligram tablet prescribed for an 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 enrollee is requesting reimbursement for the Amlodipine Besylate purchased 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, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bumetanide 2 milligram tablet prescribed for an 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 enrollee is requesting reimbursement for the Bumetanide purchased 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, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Chest Congestion Relief. 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, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Enalapril Maleate 20 milligram tablet prescribed for an 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 enrollee is requesting reimbursement for the Enalapril Maleate purchased 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, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metformin Hydrochloride extended release 24 hour 500 milligram tablet prescribed for an 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 enrollee is requesting reimbursement for the Metformin Hydrochloride purchased 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, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metoprolol Succinate extended release 24 hour 25 milligram capsule prescribed for an 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 enrollee is requesting reimbursement for the Metoprolol Succinate purchased 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, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omeprazole delayed release 40 milligram capsule prescribed for an 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 enrollee is requesting reimbursement for the Omeprazole purchased 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, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Potassium Chloride extended release 20 milliequivalent tablet prescribed for an 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 enrollee is requesting reimbursement for the Potassium Chloride purchased 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, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 50 milligram capsule prescribed for an 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 enrollee is requesting reimbursement for the Pregabalin purchased 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, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Simvastatin 20 milligram tablet prescribed for an 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 enrollee is requesting reimbursement for the Simvastatin purchased 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, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tamsulosin Hydrochloride 0.4 milligram capsule prescribed for an 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 enrollee is requesting reimbursement for the Tamsulosin Hydrochloride purchased 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, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone Cypionate 200 milligram per milliliter solution prescribed for an 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 enrollee is requesting reimbursement for the Testosterone Cypionate purchased 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, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tramadol Hydrochloride 50 milligram tablet prescribed for an 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 enrollee is requesting reimbursement for the Tramadol Hydrochloride purchased 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, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trulicity 0.75 milligram per 0.5 milliliter solution pen injector prescribed for an 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 enrollee is requesting reimbursement for the Trulicity purchased 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, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Albuterol Sulfate 2.5 milligram per 3.0 milliliter nebulizer solution to treat asthma. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that the requested drug is going to be used in the enrollees home or home-like setting with a nebulizer. Medicare classifies nebulizers as durable medical equipment. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment. Additionally, payment will be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. Coverage under Part D is excluded for any drug for which payment would be available under Part B. As such, the requested nebulizer drug is excluded from Part D coverage.This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit the request for coverage through Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

Bystolic 10 milligram tablet was requested to treat the enrollees condition. The case was auto-forwarded by the planWe 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.A request was submitted to the prescriber to provide a diagnosis, to address the nonformulary exception criteria and to provide supporting medical records. A reply from the prescriber was not received. Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

Trulicity 0.75 milligram per 0.5 milliliter pen was requested to treat the enrollees condition. 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.A request was submitted to the prescriber to provide a diagnosis and to provide supporting medical records. A reply from the prescriber was not received. Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent patch to treat chronic neuralgia. 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 Crestor 10 milligram tablet to treat pure hypercholesterolemia, unspecified. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The 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 Tremfya 100 milligram per milliliter syringe to treat psoriasis vulgaris. 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. Please note, this reconsideration decision was based on the plans 2022 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 coverage for Lyrica 100 milligram capsule to treat seizures. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.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 deemed contraindicated. In this case, the prescriber of the drug has not provided patient-specific clinical rationale, with supporting evidence, as to why the formulary alternative drug listed by the plan would likely not be as effective as the requested drug, would likely cause adverse reactions or other harm, and/or has been tried and failed. 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 a tiering exception request for Baclofen 10 milligram tablets to treat stiff-person 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.Baclofen 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.