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

At issue is Cosentyx Sensoready 150 milligram per milliliter solution to treat hidradenitis suppurativa. 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 biologic 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 biologic, as prescribed, for the treatment of this diagnosis. Therefore, the requested biologic is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Creon delayed release capsules. 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 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, it 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 Testosterone Cypionate 200 milligram per milliliter intramuscular injection solution to treat male hypogonadism. 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Everolimus 5 milligram tablets to treat metastatic breast cancer, HR positive, HER2 negative, in combination with Toremifene. 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. Medicare-approved compendia do not contain any citations to support the use of the requested drug as prescribed, for treatment of the noted diagnosis. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare. The prescriber writes that if this is not approved, the enrollee will have to start chemotherapy. The clinical situation is noted here; however Medicare is not stating the medication cannot be given; it is stating only that its' criteria are not met to be a payer source of this medication.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 Gemtesa 75 milligram tablet to treat urinary frequency and overactive bladder. 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 a tiering exception request for Entresto 97 milligram-103 milligram tablets to treat 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.Entresto 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 Aquasol A 50000 unit per milliliter injection to treat neurotrophic keratoconjunctivitis. 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 for use as vitamins and minerals 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 First-Omeprazole 2 milligram per milliliter suspension. 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 that are not approved by the Food and Drug Administration (FDA) are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sucralfate 1 gram per 10 milliliter suspension to treat gastro-esophageal reflux disease without esophagitis. 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 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 Clorazepate 7.5 milligram tablet, 120 tablets per 30 days, to treat post-traumatic stress disorder, chronic, major depressive disorder, single episode and generalized anxiety disorder. The Part D plan denied the 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 plan limits the amount of Clorazepate to 90 tablets per 30 days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the diagnosis or would be likely to cause harm. The prescriber has not indicated that a fewer number of a larger strength of the requested drug would be ineffective and inappropriate to treat the enrollee's medical condition. 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 Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Hetlioz 20 milligram capsule to treat circadian rhythm sleep disorder, free running type. 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.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 and to provide supporting medical records. 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 Morphine Sulfate extended-release 60 milligram tablets to treat carpal tunnel syndrome. 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. 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 Hetlioz 20 milligram capsule. We received the submitted documentation to perform an independent and de novo review. The submitted documentation does not include a case file from the plan or medical records. Therefore, we cannot determine if the drug was prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Kerendia 10 milligram tablets to treat chronic kidney disease in type II 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 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. 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 coverage for Procrit 4000 unit per milliliter injection solution to treat anemia associated with chronic kidney disease, not on dialysis. The Part D plan denied the request for coverage. 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.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 confirm that all of the plans coverage requirements have been met. During this review, a request was submitted to the prescriber to address the plans coverage requirements for the requested drug and to provide supporting medical records. The prescriber did not respond to the request. As such, there is insufficient documentation to support that all of the plans prior authorization criteria have 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 Pantoprazole 40 milligram powder packet for suspension to treat gastroesophageal reflux disease. The Part D plan denied the initial request for coverage. The plan then auto-forwarded the case to us for review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted.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. The prescriber did not respond to the request.Pantoprazole 40 milligram powder packet for suspension 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 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 reactions 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 coverage for Dicyclomine Hydrochloride 10 milligram capsule, 180 capsules per 90 days. 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.Initially, the prescriber/prescribers office indicated to the plan that the requested drug was prescribed to treat diarrhea due to the presence of renal cell carcinoma. However, 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.  At reconsideration, it was noted that the requested drug was actually being requested to treat diarrhea associated with irritable bowel syndrome. This is a medically accepted indication for the drug as outlined in the Medicare approved compendia. During this review, we requested additional documentation from the prescriber. Specifically, we requested medical records and a prescriber statement to clarify the condition being treated and to address the plans other coverage requirements for the drug. We received additional documentation and included it in the review. The newly submitted documentation confirms that the plans prior authorization requirements for coverage of the requested drug have been met. The submitted documentation validates that the requested drug is being prescribed to treat irritable bowel syndrome, which as noted previously, is a medically accepted indication for the drug as outlined in the Medicare approved compendia. In the submitted progress notes it is noted that the enrollee is to, Continue Bentyl [Dicyclomine Hydrochloride] for IBS [irritable bowel syndrome].' In addition, the prescriber has attested that the benefits of the requested drug outweigh the risks for the enrollee. Furthermore, the prescriber has indicated that the risks and potential side effects of the medication have been discussed with the enrollee regarding this drug, which is classified as a high-risk medication (HRM) for enrollees 65 years of age, Therefore, the newly submitted documentation supports the plans prior authorization requirements for coverage of the requested drug have been satisfied. As such, coverage for the drug can be allowed.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 Hydrocodone-Acetaminophen 7.5 milligram-325 milligram tablet. The case was auto-forwarded by the plan.We received the submitted documentation 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 provide a diagnosis, to clarify the medical history, to address the tiering exception criteria, and to provide supporting medical records. A reply from the prescriber was not received. Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication and what lower tier formulary alternatives would be appropriate, if any. Therefore, the requested 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 reimbursement for Amlodipine 5 milligram tablet prescribed to treat unspecified diagnosis. 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, that reimbursement is based on the amount paid for the drug, less any deductible, copayment or coinsurance, less the amount the pharmacy charges, and the plans approved amount. Medicare records show that SilverScript SmartRX is the enrollee's secondary insurance provider. The plan submitted documentation showing the enrollee was reimbursed for the plans share of the cost for the requested drug, based on the enrollees cost share stage. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Losartan Potassium 50 milligram tablet prescribed to treat unspecified diagnosis. 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, that reimbursement is based on the amount paid for the drug, less any deductible, copayment or coinsurance, less the amount the pharmacy charges, and the plans approved amount. Medicare records show that SilverScript SmartRX is the enrollee's secondary insurance provider. The plan submitted documentation showing the enrollee was reimbursed for the plans share of the cost for the requested drug, based on the enrollees cost share stage. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Metoprolol Succinate 100 milligram extended release tablet prescribed to treat unspecified diagnosis. 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, that reimbursement is based on the amount paid for the drug, less any deductible, copayment or coinsurance, less the amount the pharmacy charges, and the plans approved amount. Medicare records show that SilverScript SmartRX is the enrollee's secondary insurance provider. The plan submitted documentation showing the enrollee was reimbursed for the plans share of the cost for the requested drug, based on the enrollees cost share stage. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Tizanidine 2 milligram tablet prescribed to treat unspecified diagnosis. 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, that reimbursement is based on the amount paid for the drug, less any deductible, copayment or coinsurance, less the amount the pharmacy charges, and the plans approved amount. Medicare records show that SilverScript SmartRX is the enrollee's secondary insurance provider. The plan submitted documentation showing the enrollee was reimbursed for the plans share of the cost for the requested drug, based on the enrollees cost share stage. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a direct member reimbursement request for Trospium Chloride 20 milligram tablets to treat nephrolithiasis. 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

We have dismissed your reimbursement request for Phenazopyridine 200 milligram tablets because our records show your request does not have a coverage determination by the plan for the reimbursement. You must first submit your drug benefit request to the plan; if they review your case and make an unfavorable or a partially favorable decision, you may then have appeal rights to file a request for a redetermination (first level of appeal). You may file a request for reconsideration after the plan issues an unfavorable or partially favorable decision to:United States Postal Service (USPS)C2C Innovative Solutions, Inc.Part D Drug ReconsiderationsP.O. Box 44166Jacksonville, FL 32231-4166UPS / FedEx OnlyC2C Innovative Solutions, Inc.Part D QIC301 W. Bay St., Suite 600Jacksonville, FL 32202