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

At issue is coverage for Alvesco 160 microgram per actuation inhalation aerosol liquid to treat asthma and chronic obstructive pulmonary disease. 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.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that all formulary alternatives were tried and failed, or were contraindicated. We received additional documentation and included it in the review.Alvesco 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 and failed, or deemed contraindicated. In this case, the prescriber has not provided patient specific clinical rationale with supporting documentation as to why the formulary alternatives would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. 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 Travatan Z 0.004 percent ophthalmic solution to treat primary open-angle glaucoma, bilateral, mild stage. 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 a medically accepted indication, medical records, and a prescriber statement to support that all formulary alternatives were tried and failed or were contraindicated. We received additional documentation and included it in the review.The requested drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, 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 Bisacodyl 5 milligram delayed release tablet. 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 Insulin Glargine 100 unit/milliliter solution. The Part D plan auto-forwarded 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 enrollee received Insulin the self-administered drug during a hospital outpatient stay. The plan's Evidence of Coverage states, if the 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 hospital statement including the amount charged for the self-administered drug and patient payment. However, the statement indicates that a charity discount was provided, but did not provide the discount amount for each individual drug. Therefore, reimbursement amounts cannot be determined and criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Polyethylene Glycol 17 gram powder packet. 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 reimbursement for Adacel vaccine 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 documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plans Evidence of Coverage states, reimbursement for drugs administered to an enrollee for an out of network provider, or prescribers office, are based on the amount paid for the drug, less any deductible, copayment or coinsurance, less the amount the physician charges, and the plans approved amount. The plan submitted documentation showing the charge for the vaccine and administration fee indicated on the physician's billing statement was $155.00. The enrollee's copay was $45.00 and the remaining amount of $110.00 was reimbursed by the Part D plan to the enrollee on August 9, 2022. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Gabapentin, Lidocaine Hydrochloride, Diclofenac Sodium, Pentoxifylline, Cyclobenzaprine Hydrochloride, and Ibuprofen 1 percent compounded cream to treat chronic pain. The Part D plan denied the appeal request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows Gabapentin, Lidocaine Hydrochloride, Diclofenac Sodium, Pentoxifylline, Cyclobenzaprine Hydrochloride, and Ibuprofen 1 percent compounded cream was prescribed. The requested drug contains ingredients that are not United States Food and Drug Administration (FDA) approved for topical use. We determined the plan is not required to cover or allow reimbursement for the requested drug because it is excluded from coverage under 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 Allopurinol 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 plan reprocessed claims 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, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Januvia 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 plan reprocessed claims 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, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metformin Hydrochloride extended release 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 plan reprocessed claims 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, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Repatha Sureclick 140 milligram per milliliter solution to reduce the risk of myocardial infarction, stroke, and coronary revascularization in an enrollee with established cardiovascular disease and hyperlipidemia. 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 the enrollee has satisfied the plans prior authorization coverage criteria. We received additional documentation and included it in the review.The plan has prior authorization coverage criteria that must be met prior to approval. The criteria indicates the enrollee must have a Food and Drug Administration approved indication. The Medicare approved compendia contain a citation to support the use of the drug for the enrollees noted 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: Partially Favorable

At issue is coverage for Lacosamide 100 milligram tablet, 180 tablets per 60 days. The Part D plan denied the request for coverage because the amount requested exceeded the plans quantity limit for the requested drug of 60 tablets per 30 days. The Part D 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, including the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates that the requested drug has been prescribed to treat localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus. This is a medically accepted indication for the drug outlined in the Medicare approved compendia. The initial documentation submitted to the plan indicates that the prescriber is requesting 180 tablets of Lacosamide 100 milligram tablets per 60 days. The instructions written on the drug request form submitted to the plan state to take one tablet in the morning and two tablets at bedtime, which would be three tablets per day, or 90 tablets per 30 days. However, this exceeds the plans quantity limit for the drug of 60 tablets per 30 days. During this review, a request was submitted to the prescriber to address the plans quantity limit for the requested drug and to provide supporting medical records. The prescriber responded to the request. We received additional documentation and included it in the review.The prescriber is now requesting both Lacosamide 100 milligram tablets and Lacosamide 200 milligram tablets, one 100 milligram tablet to be taken in the morning and one 200 milligram tablet to be taken at bedtime. However, the only drug reviewed by the plan was Lacosamide 100 milligram tablets. As such, this second-level review can only be for Lacosamide 100 milligram tablets. If the prescriber wishes to request Lacosamide 200 milligram tablets, a separate request will have to be submitted to the plan. A physician reviewed the appeal and determined that the requested drug, Lacosamide 100 milligram tablet, is eligible for Part D coverage at an amount of 60 tablets per 30 days. As such, the decision of the QIC is partially favorable.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tretinoin 0.05 percent cream 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 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 a discount card was applied to the purchase of the requested drug. Discount cards are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When the enrollees benefit card was used, the enrollee acknowledged and agreed that the CharityRX discount program 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: Favorable

At issue is Methadone Hydrochloride 10 milligram tablet to treat chronic 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 documentation satisfies the plans coverage criteria. The prescriber has submitted medical records and a statement that confirms the increased amount of the requested drug is required to control the enrollees pain. The prescriber indicates that 500 MME per day is required to adequately manage the enrollees pain and that amount has been the same since starting the drug. The prescriber has checked the state prescription system, discussed the risks and side effects with the enrollee, and a controlled substance agreement was signed by the enrollee. The documents also show goals to increase exercise and weight loss to help with pain management. 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 Eliquis 2.5 milligram tablet prescribed for stroke recovery. 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 plans Evidence of Coverage states, limits and restrictions are placed on drugs that are refilled too soon. The submitted documentation shows the enrollee purchased the requested drug on August 23, 2021. Therefore, the claim for fill date September 21, 2021 was rejected 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 Ipratropium Bromide/Albuterol Sulfate inhalation solution 3 milligrams per 3 milliliter/0.5 milligram per 3 milliliter solution. 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.  Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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 Talicia delayed release 250/12.5/10 milligram capsule to treat helicobacter pylori gastrointestinal tract infection. The case was auto-forwarded by the plan. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The 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 Freestyle Libre 2 Sensor prescribed for type 2 diabetes mellitus without complications. 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. Supplies for testing and monitoring blood glucose levels are not considered Part D drugs and may be covered under the Medicare Part B durable medical equipment benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trulicity 0.75 milligram (mg) per 0.5 milliliter (ml) pen injector to treat type 2 diabetes mellitus without complications. 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.Trulicity is a biologic on Tier 3 of the plans formulary. There are no biologics of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this biologic 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 Repatha Sureclick 140 milligram (mg) per milliliter (ml) pen injector to treat the enrollees 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.Repatha Sureclick is a biologic on Tier 3 of the plans formulary. There are no biologic of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this biologic 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 Saxenda 18 milligram per 3 milliliter solution pen injector prescribed for diabetes. 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 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 Tymlos 80 microgram per injection pen injector to treat adult osteomalacia due to malabsorption and disorder of bone density and structure. 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 a tiering exception request for Januvia 50 milligram tablet to treat the enrollees 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.Januvia 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 coverage for Tudorza Pressair 400 microgram per actuation inhalation aerosol powder to treat moderate persistent 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 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.