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

At issue is Amitiza 24-microgram capsule to treat constipation associated with 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.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.Additionally, the prescriber request for a tiering exception for Amitiza cannot be considered at this time because the drug has been denied.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 Xarelto 20-milligram tablet for prophylaxis of thromboembolism in an enrollee with atrial fibrillation. 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.Xarelto 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 Shingrix 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 plan submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the vaccine was administered for the date of service January 15, 2021. The plans Evidence of Coverage states that enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined the amount the enrollee paid was applied to the deductible and no reimbursement is required by the plan. With regard to the second dose of Shingrix for date of service May 1, 2021, the enrollee was in the deductible stage for part of the cost for the drug and entered the initial stage for the remaining amount. The enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. After the deductible was met, the plan calculated reimbursement based on the total cost of the drug, minus the required co-payment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. We determined the Shingrix was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tremfya 100-milligram/milliliter injector 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.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 Eylea 2-milligram per 0.05-milliliter vial to treat exudative age-related macular degeneration, left eye, with active choroidal neovascularization. The Part D plan approved a recurring 30-day supply for the drug but denied the request for a 365-day supply. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.This drug has been approved by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Since the drug is a non-formulary drug, it is considered a specialty drug. Specialty drugs are limited to a recurring 30-day supply by the plan, which means the enrollee will have to get the prescription filled monthly for 12 months instead of once for the whole year. The submitted documentation does not support an exception to the plans quantity limit requirements. A physician reviewed the appeal and determined that the plan is not required to cover more than a recurring 30-day supply of the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clobetasol Propionate 0.05 percent cream to treat dermatitis, 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: Favorable

At issue is Potassium Chloride 20 milliequivalent microencapsulated tablet. The case was auto-forwarded by the plan.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 the Potassium Chloride as a self-administered drug in an outpatient stay at the hospital for date of service May 29, 2021. According to the plan's Evidence of Coverage, 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 proof of payment was provided for date of service May 29, 2021. Therefore, the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amiodarone 200 milligram tablet. The case was auto-forwarded by the plan.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 the Amiodarone as a self-administered drug in an outpatient stay at the hospital for dates of service May 28, 2021 through June 3, 2021 and June 5, 2021 through June 6, 2021. According to the plan's Evidence of Coverage, 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 for all dates of service. The enrollee's proof of payment was provided for dates of service May 28, 2021 through June 3, 2021 and the plan indicates that the claims were submitted for reprocessing. However, the enrollees proof of payment was not provided for dates of service June 5, 2021 through June 6, 2021. Therefore, reimbursement criteria have not been met for all dates of service.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azithromycin 250 milligram tablet. The case was auto-forwarded by the plan.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 the Azithromycin as a self-administered drug in an outpatient stay at the hospital for dates of service June 5, 2021 through June 6, 2021. According to the plan's Evidence of Coverage, 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 for all dates of service. The enrollee's proof of payment was not provided for dates of service June 5, 2021 through June 6, 2021. Therefore, reimbursement criteria have not been met for the dates of service requested.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Donepezil 5 milligram tablet. The case was auto-forwarded by the plan.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 the Donepezil as a self-administered drug in an outpatient stay at the hospital for dates of service May 28, 2021 through June 3, 2021 and June 5, 2021 through June 6, 2021. According to the plan's Evidence of Coverage, 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 for all dates of service. The enrollee's proof of payment was provided for dates of service May 28, 2021 through June 3, 2021 and the plan indicates that the claims were submitted for reprocessing. However, the enrollees proof of payment was not provided for dates of service June 5, 2021 through June 6, 2021. Therefore, reimbursement criteria have not been met for all dates of service.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 2.5 milligram tablet. The case was auto-forwarded by the plan.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 the Eliquis as a self-administered drug in an outpatient stay at the hospital for dates of service May 28, 2021 through June 3, 2021 and June 5, 2021 through June 6, 2021. According to the plan's Evidence of Coverage, 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 for all dates of service. The enrollee's proof of payment was provided for dates of service May 28, 2021 through June 3, 2021 and the plan indicates that the claims were submitted for reprocessing. However, the enrollees proof of payment was not provided for dates of service June 5, 2021 through June 6, 2021. Therefore, reimbursement criteria have not been met for all dates of service.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablet. The case was auto-forwarded by the plan.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 the Eliquis as a self-administered drug in an outpatient stay at the hospital for dates of service May 28, 2021 through June 3, 2021 and June 5, 2021 through June 6, 2021. According to the plan's Evidence of Coverage, 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 for all dates of service. The enrollee's proof of payment was provided for dates of service May 28, 2021 through June 3, 2021 and the plan indicates that the claims were submitted for reprocessing. However, the enrollees proof of payment was not provided for dates of service June 5, 2021 through June 6, 2021. Therefore, reimbursement criteria have not been met for all dates of service.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ferrous Sulfate 325 milligram tablet. The case was auto-forwarded by the plan.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 the Ferrous Sulfate as a self-administered drug in an outpatient stay at the hospital for dates of service June 5, 2021 through June 6, 2021. According to the plan's Evidence of Coverage, 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 for all dates of service. The enrollee's proof of payment was not provided for dates of service June 5, 2021 through June 6, 2021. Therefore, reimbursement criteria have not been met for the dates of service requested.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluocinolone 0.05 percent cream. The case was auto-forwarded by the plan.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 the Fluocinolone as a self-administered drug in an outpatient stay at the hospital for dates of service June 5, 2021 through June 6, 2021. According to the plan's Evidence of Coverage, 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 for all dates of service. The enrollee's proof of payment was not provided for dates of service June 5, 2021 through June 6, 2021. Therefore, reimbursement criteria have not been met for the dates of service requested.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gabapentin 100 milligram capsule. The case was auto-forwarded by the plan.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 the Gabapentin as a self-administered drug in an outpatient stay at the hospital for dates of service May 28, 2021 through June 3, 2021 and June 5, 2021 through June 6, 2021. According to the plan's Evidence of Coverage, 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 for all dates of service. The enrollee's proof of payment was provided for dates of service May 28, 2021 through June 3, 2021 and the plan indicates that the claims were submitted for reprocessing. However, the enrollees proof of payment was not provided for dates of service June 5, 2021 through June 6, 2021. Therefore, reimbursement criteria have not been met for all dates of service.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levothyroxine 112 microgram tablet. The case was auto-forwarded by the plan.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 the Levothyroxine as a self-administered drug in an outpatient stay at the hospital for dates of service May 28, 2021 through June 3, 2021 and June 5, 2021 through June 6, 2021. According to the plan's Evidence of Coverage, 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 for all dates of service. The enrollee's proof of payment was provided for dates of service May 28, 2021 through June 3, 2021 and the plan indicates that the claims were submitted for reprocessing. However, the enrollees proof of payment was not provided for dates of service June 5, 2021 through June 6, 2021. Therefore, reimbursement criteria have not been met for all dates of service.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pantoprazole 40 milligram tablet. The case was auto-forwarded by the plan.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 the Sertraline as a self-administered drug in an outpatient stay at the hospital for dates of service May 28, 2021 through June 3, 2021 and June 5, 2021 through June 6, 2021. According to the plan's Evidence of Coverage, 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 for all dates of service. The enrollee's proof of payment was provided for dates of service May 28, 2021 through June 3, 2021 and the plan indicates that the claims were submitted for reprocessing. However, the enrollees proof of payment was not provided for dates of service June 5, 2021 through June 6, 2021. Therefore, reimbursement criteria have not been met for all dates of service.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rosuvastatin 20 milligram tablet. The case was auto-forwarded by the plan.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 the Rosuvastatin as a self-administered drug in an outpatient stay at the hospital for dates of service May 28, 2021 through June 3, 2021 and June 5, 2021 through June 6, 2021. According to the plan's Evidence of Coverage, 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 for all dates of service. The enrollee's proof of payment was provided for dates of service May 28, 2021 through June 3, 2021 and the plan indicates that the claims were submitted for reprocessing. However, the enrollees proof of payment was not provided for dates of service June 5, 2021 through June 6, 2021. Therefore, reimbursement criteria have not been met for all dates of service.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sertraline 50 milligram tablet. The case was auto-forwarded by the plan.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 the Sertraline as a self-administered drug in an outpatient stay at the hospital for dates of service May 28, 2021 through June 3, 2021 and June 5, 2021 through June 6, 2021. According to the plan's Evidence of Coverage, 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 for all dates of service. The enrollee's proof of payment was provided for dates of service May 28, 2021 through June 3, 2021 and the plan indicates that the claims were submitted for reprocessing. However, the enrollees proof of payment was not provided for dates of service June 5, 2021 through June 6, 2021. Therefore, reimbursement criteria have not been met for all dates of service.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lortab 10-300-milligram/15-milliliter elixir to treat connective tissue and disc stenosis of intervertebral foramina of lumbar region. 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.