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

At issue is Victoza 2 pak 18 milligram per 3 milliliter solution pen injector prescribed for an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for the requested drug were approved and copayment was charged to the enrollee at the point of sale for 2022 date of fill. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copay amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. We determined the copay of $47.00 for the date of fill in 2022 was charged correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vitamin D2 1.25 milligram (50,000 unit) capsule. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed 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 Vitamin D3 1000 unit tablet. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage for all dates of service in 2021.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is B Vitamin Complex 30 milliliter injection to treat 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, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed for use as vitamins and minerals are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Total Cobalamin (B12) 30 milliliter injection to treat 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, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed for use as vitamins and minerals are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amoxicillin/Clavulanate Potassium. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. The plan indicates that the amount of refund to the enrollee was due to an incorrect copay amount for the cost share stage at the time of purchase. Therefore, no additional reimbursement is due.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benazepril Hydrochloride/Hydrochlorothiazide. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. The plan indicates that the amount of refund to the enrollee was due to an incorrect copay amount for the cost share stage at the time of purchase. Therefore, no additional reimbursement is due.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clonidine Hydrochloride. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. The plan indicates that the amount of refund to the enrollee was due to an incorrect copay amount for the cost share stage at the time of purchase. Therefore, no additional reimbursement is due.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluocinolone Acetonide. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. The plan indicates that the amount of refund to the enrollee was due to an incorrect copay amount for the cost share stage at the time of purchase. Therefore, no additional reimbursement is due.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocodone Bitartrate/Acetaminophen. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. The plan indicates that the amount of refund to the enrollee was due to an incorrect copay amount for the cost share stage at the time of purchase. Therefore, no additional reimbursement is due.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol Sulfate Hydrofluoroalkane (HFA) 90 microgram inhaler. 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 plan reprocessed a claim for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, there is evidence to support that the plan issued a recovery notice within 45 days of the plans receipt of complete information regarding the claims adjustment. Therefore, the enrollee is responsible for their share of any copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Stiolto Respimat inhaler prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed a claim for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, there is evidence to support that the plan issued a recovery notice within 45 days of the plans receipt of complete information regarding the claims adjustment. Therefore, the enrollee is responsible for their share of any copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Cinacalcet Hydrochloride 30 milligram tablet to treat secondary hyperparathyroidism associated with chronic kidney disease. The Part D plan denied the request for coverage, stating that the drug would be covered under Medicare Part B, as the medication was being prescribed for a dialysis-related purpose. The plan 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 documentation submitted. Additionally, we researched Medicare systems.Drugs used for dialysis-related purposes for enrollees with end-stage renal disease coverage receiving dialysis would be available for coverage under Medicare Part B. However, there is no indication in the Medicare systems that the enrollee has end-stage renal disease coverage and/or is receiving dialysis. During this review, we requested a prescriber statement and medical records to clarify whether or not the enrollee is currently receiving dialysis. The prescriber responded, and the additional documentation has been included in the review.The prescriber verified that the enrollee was not receiving dialysis. However, using the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support using the requested drug to treat secondary hyperparathyroidism associated with chronic kidney disease when the enrollee is not receiving dialysis. As outlined in the Medicare-approved compendia and the Food and Drug Administration product label, Cinacalcet is not to be used in patients with chronic kidney disease who are not receiving dialysis, as hypocalcemia may occur. As such, 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 Cresemba 186 milligram capsule for prophylaxis against aspergillus and mucormycosis following 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.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support a covered diagnosis and that all formulary alternatives were tried and failed or were contraindicated. We received additional documentation and included it in the review.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 Tramadol Hydrochloride 50 milligram tablet. The Part D plan denied the request.We received the submitted documentation to perform an independent and de novo review.A request was submitted to the prescriber to provide a diagnosis, to clarify the medical history, and to provide supporting medical records. A reply from the prescriber was not received. The submitted documentation does not include medical records or evidence of the medical necessity of the prescribed drug. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Stelara 90 milligram per milliliter syringe 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.This biologic is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier biologics are not available for a tiering exception per Medicare rules.A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolastin C 1000 milligram for IV infusion to treat congenital alpha-1 antitrypsin (AAT) deficiency without emphysema. 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 Wegovy 2.4 milligram per 0.75 milliliter pen to treat obesity. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed to treat weight gain (promote weight loss) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Methenamine Hippurate 1 gram tablet to treat the patient's condition. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Methenamine Hippurate 1 gram tablet is a generic drug on Tier 3 of the plans formulary. There are no brand or generic 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 a tiering exception request for Entecavir 0.5 milligram tablet to treat chronic hepatitis B. 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.  Entecavir 0.5 milligram tablet is a generic drug on Tier 4 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 Xtampza ER (extended release) 9 milligram sprinkle capsule to treat chronic neuropathic pain. 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: Favorable

At issue is Shingrix 50 micrograms per 0.5 milliliter, single dose as a preventative vaccine. 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 limits the amount of Shingrix 50 microgram per 0.5 milliliter to 2 doses per lifetime. The provider has submitted medical records that support the patient has only received one Shingrix vaccine. Prior vaccination was with a live virus vaccine and a single dose of the recombinant vaccine, Shingrix. The requested quantity is within the plans allowed quantity limit.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 Mounjaro 2.5 milligram per 0.5 milliliter pen injector to treat the patient's condition. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Mounjaro 2.5 milligram per 0.5 milliliter pen injector 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: Favorable

At issue is Eliquis 5 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 a 90 day refill of Eliquis was requested by the enrollee from the plan's mail order pharmacy on December 15, 2022. The plan indicated to the enrollee that a 90 day fill would compromise the auto refill for a 30 day supply that the mail order pharmacy had on file. It was explained to the enrollee that a 90 day refill could be processed immediately with a charge of $168.38, but a 30 day supply could take 7-10 business days to be received, as the auto refill did not process for the month of December. The enrollee states that an agreement was made to process the 90 day supply, as he would have run out of the drug before the 30 day supply would arrive. However, in this case the enrollee received a 30 day supply of the tier 3 drug and was charged $123.38. According to the Evidence of Coverage, the copay for a tier 3 drug should have been $37.00. Therefore, we determined the plan is required to reimburse the enrollee for the cost of the covered drug $123.38, minus the copay amount of $37.00, due to mail order error.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Klisyri 1 percent topical ointment to treat actinic keratosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.In the reconsideration appeal the prescriber submitted documentation of drug trials of both Imiquimod and Fluorouracil. The information included the trial dates and adverse outcomes. The prescriber has indicated why all alternatives required by the plan would likely not be as effective as the requested drug for the treatment of the diagnosis. Therefore, an exception to the plans 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 Gammagard 5 grams per 50 milliliters solution to treat other complications of lung 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.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 Xeljanz XR (extended release) 22 milligram tablet, 90 day supply, to treat ulcerative colitis. 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.The plan limits the quantity of Xeljanz XR to a 30 day supply. As the drug has not been approved for coverage, a quantity limit exception cannot be granted. 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 Hydroxyzine Hydrochloride 25 milligram tablets to treat anxiety. 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.