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

At issue is a tiering exception request for Sevelemar Carbonate 800-milligram tablet to treat the enrollee'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.This drug is being provided 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. Per Medicare rules, non-formulary drugs/biologics are 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 Abilify 20-milligram tablet and a 90 day supply. The Part D plan denied the request for a 90 day supply but approved a recurring 30 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.The plan limits the amount of Abilify tablets provided as a 30-day supply as it is a non-formulary drug. Therefore, an exception to the plans coverage criteria is not supported. A physician reviewed the appeal and determined that the requested drug is not eligible for a 90 day supply of drugs covered under formulary exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5-percent patch to treat chronic mid-back 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.We requested additional information from the prescriber. Specifically, we requested the prescriber to provide supporting medical documentation to confirm the diagnosis related to the requested drug. We also requested documentation to support that the enrollee has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information.Upon the redetermination, the plan denied the appeal request stating the prior authorization criteria was not met. However, no medical records have been provided to determine if this enrollee has met the criteria for a medically acceptable indication per the approved Medicare compendia. Therefore, the drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Restasis 0.05-percent ophthalmic dropperettes to treat dry eye syndrome of bilateral lacrimal glands. 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 Part D plan has prior authorization requirements that have to be met before coverage of this drug is approved. The submitted documentation does not satisfy the plans coverage criteria. During this review, a request was submitted to the prescriber to address the plans coverage requirements for the medication. The prescriber did not respond to the request. As such, the prior authorization criteria have not been satisfied. 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 Hetlioz 20 milligram capsules prescribed for the management of circadian rhythm sleep disorder free run type, non-24-hour sleep-wake disorder. 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 plan has prior authorization requirements for this drug that must be met before coverage can be approved. The submitted documentation does not confirm that all of the plans requirements for coverage have been met. During this review, we requested medical records and a prescriber statement from the prescriber to validate that the plans coverage requirements for the requested drug were met. However, we did not receive a response from the prescriber. As such, there is insufficient documentation to validate whether the plans prior authorization criteria have 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 Ketamine Hydrochloride powder, Gabapentin powder, Diclofenac Sodium powder, Bupivacaine Monohydrate Hydrochloride and base PermE8 Anhydrous gel. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your 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 you were prescribed Ketamine Hydrochloride powder, Gabapentin powder, Diclofenac Sodium powder, Bupivacaine Monohydrate Hydrochloride and base PermE8 Anhydrous gel from bulk powders. Drugs compounded from bulk powders are not Food and Drug Administration approved and are therefore not covered under Part D.We determined that the plan is not required to reimburse the Ketamine Hydrochloride powder, Gabapentin powder, Diclofenac Sodium powder, Bupivacaine Monohydrate Hydrochloride and base PermE8 Anhydrous gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a 2022 plan year tiering exception request for Rivastigmine Tartrate 6-miliigram capsules to treat Alzheimers 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.Rivastigmine Tartrate is a generic drug on Tier 3 of the plans 2022 formulary. The prescriber has not provided sufficient patient specific clinical rationale as to why each lower-tiered drug on the plans formulary to treat the enrollees condition has been tried and failed, or is contraindicated. Therefore, the tiering exception criteria have not been met. As such, the requested drug is not eligible for a 2022 plan year tiering exception.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Ursodiol 500-milligram tablets to treat primary biliary cholangitis. 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.Ursodiol is a generic drug on Tier 3 of the plans formulary. There are no 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 2022 plan year tiering exception request for Eliquis 5-milligram 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.Eliquis 5-milligram tablet 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. Please note, this reconsideration decision was based on the plans 2022 coverage criteria.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armodafinil 50-milligram tablet to treat chronic fatigue associated with primary biliary cirrhosis. 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 reimbursement for Tetanus, Diphtheria, and Pertussis (Tdap) vaccine combination administered for preventative care. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that the enrollee received the Tetanus, Diphtheria, and Pertussis vaccine combination on August 19, 2021, while at the doctors office. The enrollees Part D plan requires proof of payment from the doctors office. There is no documentation indicating the enrollee paid for the requested drug. The enrollee did not provide proof of payment.We determined that the plan is not required to cover this vaccination because the enrollee has not submitted the proof of payment from the doctors office.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gamunex-C 20-milligram/2-milliliter solution to treat chronic inflammatory demyelinating polyradiculoneuropathy. 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.A request was submitted to the prescriber to clarify the medical history, to address the prior authorization criteria including if the enrollee was to receive the drug in the home, and to provide supporting medical records. However, we did not receive the requested information.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eligard 22.5-milligram kit prescribed for malignant neoplasm of prostate. 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 furnished Incident To a physicians service are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Prolia 60 milligram per milliliter prefilled subcutaneous injection syringe to treat postmenopausal osteoporosis in an enrollee who is at high risk for fracture. 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.During this review, we requested medical records and a prescriber statement to confirm the plans prior authorization requirements were met. We received additional documentation and included it in the review.The plan has prior authorization requirements for this drug that must be met before coverage can be approved. The submitted documentation does not support that all of the plans requirements for coverage have been met.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage. Please note, this reconsideration decision was based on the Plans 2021 coverage criteria.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Prolia 60 milligram per milliliter prefilled subcutaneous injection syringe to treat postmenopausal osteoporosis in an enrollee who is at high risk for fracture. 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.During this review, we requested medical records and a prescriber statement to confirm the plans prior authorization requirements were met. We received additional documentation and included it in the review.The plan has prior authorization requirements for this drug that must be met before coverage can be approved. The submitted documentation does not support that all of the plans requirements for coverage have been met.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage. Please note, this reconsideration decision was based on the Plans 2022 coverage criteria.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue coverage for Nystop 100,000-unit per gram topical powder prescribed for an unknown condition. 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 available documentation does not include any medical records from the prescriber nor the enrollees diagnosis. During this review, a request was submitted to the prescriber to provide the diagnosis and supporting medical records. The prescriber did not respond to the request. Without a diagnosis, it cannot be determined if the drug is being prescribed for a medically accepted indication outlined in the Medicare approved compendia. As such, the drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Qulipta 60-milligram tablet to treat chronic migraines. The case was auto-forwarded from 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.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed or were contraindicated. However, we did not receive the requested information.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 Trulicity 3-milligram/0.5-milliliter pen injector to treat obesity and pre-diabetes. 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 2022 plan year tiering exception request for Xarelto 20-milligram tablets prescribed for anticoagulation therapy in an enrollee with atrial fibrillation and congestive heart failure. 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 2022 formulary. There are no brand drugs of the same type to treat the noted condition on the lower tiers of the plans formulary. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. As such, the requested drug is not eligible for a 2022 plan year tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tazarotene 0.1-percent cream to treat skin neoplasm of uncertain behavior and 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.The use of the requested drug to treat the provided diagnoses 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 these diagnosis. Therefore, the requested drug 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 Pulmozyme 2.5-milligram/2.5-milliliter nebulizer 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 coverage for Gammaplex 10-gram per 100-milliliter solution to treat other specified immunodeficiencies with evidence of decreased switched memory B cells in the setting ofrecurrent pneumonias complicated by bronchiectasis. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diphtheria, Tetanus, and Acellular Pertussis Booster vaccination. The Part D plan denied the request as an excluded drug in the Medicare Part D program.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.For the drug at issue to be covered under Medicare Part D, the manufacturer must participate in the Medicare Coverage Gap Discount Program. This manufacturer is not participating in the program; therefore, the drug is excluded from Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xopenex 1.25-milligram/3-milliliter nebulizer 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 a 2022 Plan Year tiering exception request for Xarelto 2.5-milligram tablets to treat atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs. 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 2022 formulary. There are no brand drugs of the same type on the lower tiers of the plans 2022 formulary to treat the same diagnosis. Therefore, this drug is not eligible for a 2022 Plan Year tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxistat 1-percent lotion to treat tinea unguium. 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.