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

At issue is Botox 10 unit solution reconstituted to treat 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. Please note, this reconsideration decision was based on the plans 2022 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 Hydrocodone Bitartrate extended release 20 milligram 24 hour to treat spinal stenosis, lumbar region with neurogenic claudication, pain in right hip, primary osteoarthritis, and other chronic pain. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The 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.Additionally, the plan limits the amount of Hydrocodone Bitartrate extended release 20 milligram 24 hour to 30 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. 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 Mycophenolate Mofetil 200 milligram per milliliter suspension to treat dysphasia, drug rash with eosinophilia, and systemic symptom. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Ozempic 0.25 or 0.5 milligrams per dose (2 milligrams per 1.5 milliliters) pen injector to treat the enrollees condition. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Ozempic 0.25 or 0.5 milligrams per dose (2 milligrams per 1.5 milliliters) pen injector 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 Bumetanide 1 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for reimbursement.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 enrollee is requesting reimbursement for the Bumetanide purchased from a Walmart pharmacy on date of service October 6, 2022 because the mail order from divvyDOSE was stolen from the enrollees mailbox, and the enrollee had to purchase the drug from a net-work pharmacy on the same date of service. However, the plan submitted documentation showing the claim from divvyDOSE was reversed. Therefore, the evidence does not support reimbursement for the copay charge at Walmart.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clopidogrel Bisulfate 75 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for reimbursement.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 enrollee is requesting reimbursement for the Clopidogrel Bisulfate purchased from a Walmart pharmacy on date of service October 6, 2022 because the mail order from divvyDOSE was stolen from the enrollees mailbox, and the enrollee had to purchase the drug from a net-work pharmacy on the same date of service. However, the plan submitted documentation showing the claim from divvyDOSE was reversed. Therefore, the evidence does not support reimbursement for the copay charge at Walmart.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Farxiga 10 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for reimbursement.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 enrollee is requesting reimbursement for the Farxiga purchased from a Walmart pharmacy on date of service October 6, 2022 because the mail order from divvyDOSE was stolen from the enrollees mailbox, and the enrollee had to purchase the drug from a net-work pharmacy on the same date of service. However, the plan submitted documentation showing the claim from divvyDOSE was reversed. Therefore, the evidence does not support reimbursement for the copay charge at Walmart.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lantus 100 unit/milliliter solution prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for reimbursement.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 enrollee is requesting reimbursement for the Lantus purchased from a Walmart pharmacy on date of service October 6, 2022 because the mail order from divvyDOSE was stolen from the enrollees mailbox, and the enrollee had to purchase the drug from a net-work pharmacy on the same date of service. However, the plan submitted documentation showing the claim from divvyDOSE was reversed. Therefore, the evidence does not support reimbursement for the copay charge at Walmart.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Magnesium Oxide 400 milligram tablet. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pantoprazole Sodium delayed release 20 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for reimbursement.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 enrollee is requesting reimbursement for the Pantoprazole Sodium purchased from a Walmart pharmacy on date of service October 6, 2022 because the mail order from divvyDOSE was stolen from the enrollees mailbox, and the enrollee had to purchase the drug from a net-work pharmacy on the same date of service. However, the plan submitted documentation showing the claim from divvyDOSE was reversed. Therefore, the evidence does not support reimbursement for the copay charge at Walmart.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Potassium Chloride extended release 10 milliequivalent tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for reimbursement.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 enrollee is requesting reimbursement for the Potassium Chloride purchased from a Walmart pharmacy on date of service October 6, 2022 because the mail order from divvyDOSE was stolen from the enrollees mailbox, and the enrollee had to purchase the drug from a net-work pharmacy on the same date of service. However, the plan submitted documentation showing the claim from divvyDOSE was reversed. Therefore, the evidence does not support reimbursement for the copay charge at Walmart.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Risperidone 2 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for reimbursement.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 enrollee is requesting reimbursement for the Risperidone purchased from a Walmart pharmacy on date of service October 6, 2022 because the mail order from divvyDOSE was stolen from the enrollees mailbox, and the enrollee had to purchase the drug from a net-work pharmacy on the same date of service. However, the plan submitted documentation showing the claim from divvyDOSE was reversed. Therefore, the evidence does not support reimbursement for the copay charge at Walmart.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira CF (Citrate Free) 80 milligram per 0.8 milliliter/40 milligram per 0.4 milliliter pen injector kit to treat granuloma annulare. 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. Please note, this reconsideration decision was based on the plans 2023 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 Procrit 10000 unit per milliliter solution to treat anemia in chronic kidney 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 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 coverage for Lidocaine 5 percent patch to treat pain due to rheumatoid arthritis, unspecified; spinal stenosis, cervical region; and other spondylosis with myelopathy, cervical region. 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 noted conditions are off-label uses for the requested drug. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. Therefore, the drug is being prescribed for non-medically accepted indications.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 Acthar Gel 400 unit per 5 milliliter vial to treat keratoconjunctivitis sicca. The Part D plan denied the request for coverage because the drug was not being prescribed for a medically accepted indication. 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 keratoconjunctivitis sicca, which is a chronic inflammatory disorder of the eye, is a medically accepted indication for the drug as outlined in the Medicare approved compendia. However, 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 deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why all of the plans formulary alternative drugs 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. Therefore, the formulary exception criteria have not been met.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Tazarotene 0.1 percent cream to treat Darier'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 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 coverage for Promethazine Hydrochloride 25 milligram tablet to treat nausea and vomiting due to gastroparesis. 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 a tiering exception request for Invokana 100 milligram tablet to treat type 2 diabetes mellitus with hyperglycemia. 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.Invokana 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 a tiering exception request for Invokana 100 milligram tablet to treat type 2 diabetes mellitus with hyperglycemia. 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.Invokana 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 2023 coverage criteria.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligrams per milliliter solution auto-injector to treat hyperlipidemia in patients with clinical atherosclerotic cardiovascular 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 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: Favorable

At issue is Dronabinol 2.5 milligram capsule to treat nausea and vomiting associated with chemotherapy. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The documentation satisfies the plans coverage criteria. The prescriber provided patient specific clinical rationale supported by documentation indicating the brand name Marinol (generic Dronabinol) will be used in conjunction with Zofran. The plan approved the brand Marinol from December 15, 2022, through December 15, 2023. As such, the on-formulary generic form, Dronabinol, is approved.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 Humira 40 milligram per 0.4 milliliter subcutaneous solution to treat relapsing polychondritis. 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 Zioptan 0.0015 percent ophthalmic solution prescribed for primary open angle glaucoma. 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. According to Medicare rules, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. According to the list, the manufacturer, Thea Pharma Incorporated, did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, we determined that the plan is not required to cover the Zioptan. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Korlym 300 milligram tablets to treat Cushing syndrome, 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 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 Sildenafil Citrate 100 milligram tablet to treat an 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, including the case file from the plan, and any information submitted at the reconsideration level. Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other diagnoses for which the drug is not Food and Drug Administration (FDA) approved, 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 Nicotine 7 milligrams per 24 hour patch. 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 that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.