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

At issue is coverage for Diphenhydramine compound drug. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The record shows the Diphenhydramine is part of a compounded drug and each ingredient is reviewed individually. Diphenhydramine is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Mylanta compound drug. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The record shows the Mylanta is part of a compounded drug and each ingredient is reviewed individually. Mylanta is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Tadalafil 20 milligram tablet to treat pulmonary arterial hypertension, World Health Organization (WHO) Group 1. The Part D plan denied the request for coverage stating that drugs used to treat erectile dysfunction are excluded from Part D coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to clarify the condition being treated and to address the plans prior authorization coverage criteria for the drug. We received additional documentation and included it in the review. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The requested drug, Tadalafil 20 milligram tablet, is not being prescribed to treat erectile dysfunction. Furthermore, as outlined in the Medicare approved compendia, Tadalafil in the 20 milligram tablet strength is not indicated for the treatment of erectile dysfunction. The use of the requested drug to treat the provided diagnosis of pulmonary arterial hypertension, World Health Organization (WHO) Group 1, is a medically accepted indication for the drug as outlined in the Medicare approved compendia. Therefore, the drug is being prescribed for a Part D covered medically accepted indication.However, the plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted does not validate that all of the plans requirements for coverage have been satisfied, as no right heart catheterization results confirming the diagnosis of pulmonary arterial hypertension have been submitted, as required. 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 Humalog 10 unit per milliliter vial 50-day supply to treat the enrollee's condition. 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 paid 2 copays of $15.81 for the purchase of Humalog from a network pharmacy. Medicare rules state, that beginning January 1, 2023, Part D plans will offer coverage for all formulary insulin at a $35.00 (or less) monthly (30 day) copay throughout all cost share phases of the Part D benefit plan. In this case, we determined that the plan's charge of $15.81 was calculated correctly for the day's supply received by the enrollee and no additional reimbursement is due.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Cyclobenzaprine Hydrochloride 10 milligram tablet to treat chronic muscle spasm of the back. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Dupixent 300 milligram per 2 milliliter pen to treat atopic dermatitis. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Dupixent 300 milligram per 2 milliliter solution pen-injector to treat severe 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 available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not confirm that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Dupixent 300 milligrams per 2 milliliter solution pen-injector to treat atopic dermatitis. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Prevident 5000 plus 1.1 precent toothpaste to treat dental caries prophylaxis. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Prevident 5000 plus 1.1 percent toothpaste has not been found by the Food and Drug Administration (FDA) to be safe and effective, and the drug product labeling has not been approved by the FDA. Drugs that are not FDA-approved do not meet the definition of a Part D drug and are excluded from Part D coverage. Therefore, the requested drug is excluded from Medicare Part D coverage.This decision does not address the medical necessity of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Calcipotriene 0.005 percent cream to treat unspecified dermatitis, actinic keratoses. The Part D plan denied the request for coverage.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication. 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 reimbursement for a Tetanus Diphtheria Toxoids vaccine 10 milligram per milliliter solution 2 milliliter vial and administration fee. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The itemized bill received shows the enrollee received a Tetanus Diphtheria Toxoids vaccine on March 29, 2023. The statement shows the Tetanus Diphtheria Toxoids charge was $141.21 and the charge for administration of the vaccine was $68.00. A total of $209.21 was paid by the enrollee on July 13, 2023, per the prescribers statement. The drug is on the plans formulary. The documentation is sufficient to support reimbursement for the vaccine and administration fee. Therefore, we determined that the plan is required to reimburse the enrollee $209.21 for the cost of the Tetanus Diphtheria Toxoids vaccine and administration fee for the date of service March 29, 2023.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Insulin 28 gauge x 12.7 millimeter syringe/needle for an enrollee with type 2 diabetes mellitus with diabetic neuropathy. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The record shows the enrollee submitted a request for refill for multiple diabetic supplies including Insulin 28 gauge x 12.7 syringe/needles. The plans Evidence of Coverage states if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug was not provided. Therefore, we determined that the plan is not required to provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Repatha SureClick 140 milligram per milliliter solution to treat primary hyperlipidemia. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements have not been met.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Wegovy 0.5 milligram per 0.5 milliliter auto-injector for weight loss. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. Drugs prescribed to treat obesity and/or to promote weight loss are excluded from the Part D coverage. Therefore, the requested drug is excluded from Medicare 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Olopatadine Hydrochloride 0.2 percent ophthalmic solution to treat acute atopic conjunctivitis, unspecified eye. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Olopatadine Hydrochloride 0.2 percent ophthalmic solution is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Austedo 12 milligram tablet to treat tardive dyskinesia with chorea. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Ruxience 500 milligram per 50 milliliter solution to treat idiopathic retroperitoneal fibrosis. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Nexlizet 180/10 milligram tablet to treat atherosclerotic heart disease of native coronary artery, with mixed hyperlipidemia. The Part D plan denied the request for coverage.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements have not been met. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Cyclobenzaprine Hydrochloride 5 milligram tablet to treat sciatica, chronic musculoskeletal pain. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication. 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 Mycophenolate Mofetil 500 milligram tablet to treat Sjogren's disease. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.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 Kerendia 20 milligram tablet to treat chronic kidney disease. The Part D plan denied the request for coverage.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Lumigan 0.01 percent solution to treat glaucoma. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. Lumigan 0.01 percent solution is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception.  A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Sildenafil 50 milligram tablet to treat post-prostatectomy erectile dysfunction due to the presence of prostate cancer. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Drugs prescribed to treat sexual or erectile dysfunction are excluded from the Part D coverage. Therefore, the requested drug is excluded from Medicare 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Fasenra 30 milligram per milliliter subcutaneous solution auto-injector to treat eosinophilic cystitis. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Wegovy 0.25 milligrams per 0.5 milliliter pen to treat weight gain. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Drugs prescribed to treat obesity and/or to promote weight loss are excluded from the Part D coverage. Therefore, the requested drug is excluded from Medicare 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Ozempic 2 milligram per 0.75 milliliter pen injector to treat type 2 diabetes mellitus. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Ozempic is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5 milligram tablet for thromboembolism prophylaxis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Eliquis 5 milligram tablet is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.