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

You asked the Plan to cover Diclofenac Sodium 1% Gel. The Plan did not grant this request. We receivedthis case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Diclofenac Sodium 1% Gel.The drug is requested to treat rheumatoid arthritis, unspecified, which is an off-label (non-FDA approved)use. The Medicare-approved compendia do not contain any citations to support the use of the requesteddrug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is not beingprescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions requestbased on medical necessity cannot be considered because the requested drug, as prescribed, does not meetthe definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage underMedicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Diclofenac Sodium 1% Gel for the diagnosed condition. As aresult, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. Assuch, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions requestbased on medical necessity cannot be considered because this drug, as prescribed, does not meet thedefinition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to providecoverage for Diclofenac Sodium 1% Gel.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Promethazine. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Promethazine. The drug is requested to treat nausea due to migraine, which is an off-label (non-FDA approved) use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Promethazine for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Promethazine. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Phosphorous Powder Packet . The Plan did not grant this request. We receivedthis case to conduct an independent review.Medicare law excludes certain drugs from Part D coverage. Phosphorous Powder Packet is one of thoseexcluded drugs because it is a prescription vitamin and mineral product. The record submitted by the Plandoes not indicate that they provide supplemental coverage for Phosphorous Powder Packet. Therefore, thePlan is not required to cover Phosphorous Powder Packet.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Omeprazole DR 20 mg capsule, 60 capsules per 30 days. The Plan did notgrant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Omeprazole DR 20 mg capsule, 60 capsules per 30 days. The drug is requested to treat K21.9 - Gastroesophagealreflux disease without esophagitis. The Plan limits the amount of Omeprazole DR 20 mgcapsule to 30 capsules per 30 days. You sent a statement dated July 2, 2020 clarifying the medical history.You state that a fewer number of a greater strength pill/tablet (ie Omeprazole DR 40 mg capsule) would bean appropriate option for the treatment of the enrollee's condition. Omeprazole DR 40 mg capsule isavailable on the Plan's formulary with a quantity limit of 60 capsules per 30 days. You have not indicatedthat the number of doses of the formulary alternative Omeprazole DR 40 mg capsule allowed by the Planwould likely be ineffective in treating the enrollee's condition and/or would likely cause harm to theenrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer'sopinion is that quantity limit exception criteria are not met.Medicare rules allow a Part D Plan to manage its formulary by covering a limited quantity of certain drugs.A Plan must grant an exception if it determines that the requested dosage is medically reasonable andnecessary, consistent with the prescriber's statement. Based on a review of the available documentation,our Physician Reviewer's opinion is that an exception to the quantity limit criteria is not met. Therefore, thePlan is not required to cover the requested quantity of Omeprazole DR 20 mg capsule.
Appeal type: Prescription Drug
Decision: Partially Favorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Acetaminophen 325, Latanoprost 0.005%, Losartan 50mg, NACL 0.9%, Sodium Chloride 0.9%, Oxymetazoline 0.05% and Potassium Chloride 20 meq receivedFebruary 24, 2020 through February 26, 2020. The Plan did not grant this request. We received this case toconduct an independent review.Latanoprost 0.005%, Losartan 50 mg, NACL 0.9%, and Potassium Chloride 20 meqThe Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances.In this case, you were at the hospital for an emergency or urgent care situation. You received several selfadministereddrugs during this stay. You requested reimbursement from the Part D Plan. The requestincludes an itemized statement for the hospital stay and proof of payment in full for the self-administereddrugs. Latanoprost 0.005%, Losartan 50 mg, NACL 0.9% and Potassium Chloride 20 meq are Part Deligible drugs. The Plan has not processed the request for reimbursement for Latanoprost 0.005%, Losartan50 mg, NACL 0.9%, and Potassium Chloride 20 meq at this time. The Plan's out-of-network coveragerules were followed. Therefore, our decision is the Plan is required to provide coverage and providereimbursement for Latanoprost 0.005%, Losartan 50 mg, NACL 0.9% and Potassium Chloride 20 meqreceived February 24, 2020 through February 26, 2020.Acetaminophen 325 mg and Oxymetazoline 0.05%Medicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drugs'classification or determined from other available resources that the drugs are non-prescription or OTCdrugs. Therefore, Acetaminophen 325 mg and Oxymetazoline 0.05% are not eligible for Part D coverage,and the Plan is not required to cover or provide reimbursement for them under the Part D benefit.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes that payment cannot be made under the Medicare Part D benefit.Sodium Chloride 0.9%Sodium Chloride 0.9% received February 24, 2020 through February 26, 2020 was not billed as a selfadministereddrug. Therefore, the Part D Plan is not required to cover or provide reimbursement for it.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Risedronate Sodium DR. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Risedronate Sodium DR 35 mg. The drug is requested to treat osteoporosis. You have not indicated why all alternatives required by the Plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are not met. Therefore, the Plan is not required to cover Risedronate Sodium DR.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for the Estriol ingredient of the Testosterone-Estradiol-Estriol-Progesterone Compound purchased February 5, 2020. The Plan did not grant this request. Wereceived this case to conduct an independent review.Medicare Part D does not cover drugs that are not FDA approved. A representative of the pharmacy statedthe Estriol ingredient of the Testosterone-Estradiol-Estriol-Progesterone Compound purchased February 5,2020 is a bulk powder. Bulk powders used in pharmacy compounding are not reviewed and approved forsafety and efficacy by the FDA. Therefore, the Plan is not required to cover or provide reimbursement forthe Estriol ingredient of the Testosterone-Estradiol-Estriol-Progesterone Compound purchased February 5,2020.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Ilevro. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Ilevro. The drug is requested to treat nonexudative age-related macular degeneration, bilateral, stage unspecified and inflamed retina (no indication of recent cataract surgery), which are off-label (non-FDA approved) uses. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted conditions. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted conditions.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Ilevro for the diagnosed conditions. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for these conditions. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Ilevro. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Freestyle Libre. The Plan did not grant this request. We received this case toconduct an independent review.Medicare Part D does not cover devices. Freestyle Libre has been classified by the FDA as a device, not asa drug. Therefore, our decision is the Part D Plan is not required to cover Freestyle Libre.This decision does not address the medical necessity or appropriateness of the requested item. It onlyestablishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Menostar 14 mcg/24 hr patch. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Menostar 14 mcg/24 hr patch.The drug is requested to treat osteoporosis. A request for prescriber statement and medical records was sent. The statement was returned without records. The prescriber has not provided a sufficient medical rationale supported with records to support the diagnosis and why the Plan's alternatives would not be appropriate for the enrollee. The prescriber has not indicated why all alternatives required by the Plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are not met. Therefore, the Plan is not required to cover Menostar 14 mcg/24 hr patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Bystolic. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for a tiering exception for Bystolic. The drug is requested to treat your cardiac arrhythmia. The drug is on Tier 4 of the Plan's formulary. There are no available (equivalent, branded) lower tier drugs on the Plan's formulary to treat your condition. Therefore, the drug is not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug is being used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met because there are no lower cost-sharing tiered drugs of the same type for treating the enrollee's condition. Therefore, our decision is the Plan is not required to provide a tiering exception for Bystolic.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Nucynta. The Plan did not grant this request. We received this case to conductan independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Nucynta 50 mg tablet. The drug is requested to treat non-acute pain related to lumbar disc herniationand systemic lupus erythematosus, which is an off-label (non-FDA approved) use. The Medicare-approvedcompendia do not contain any citations to support the use of the requested drug, as prescribed, for treatmentof the noted condition. Therefore, the requested drug is not being prescribed for a medically acceptedindication as defined by Medicare law. As such, an exceptions request based on medical necessity cannotbe considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part Ddrug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the notedcondition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Nucynta for the diagnosed condition. As a result, the drug isnot being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot becovered under the Medicare Part D benefit for this condition. An exceptions request based on medicalnecessity cannot be considered because this drug, as prescribed, does not meet the definition of a MedicarePart D drug. Therefore, our decision is that the Plan is not required to provide coverage for Nucynta.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to provide additional reimbursement for Losartan Potassium 25 mg purchased March 20, 2020. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. If you pay the full cost of a prescription drug out-of-pocket or if you find you have paid more than you expected to pay under the Plan's coverage rules, you can ask the Plan to pay you back. When submitting a request for reimbursement, the Plan requires that you submit your receipt documenting the payment you have made along with your reimbursement request.In this case, the enrollee purchased Losartan Potassium 25 mg, as a quantity of 60 tablets per 30 days on March 20, 2020. The enrollee paid the full cost at the time of purchase because Losartan Potassium 25 mg has a quantity limit of 30 per 30 days. The Plan subsequently approved the quantity limit exception and provided coverage and reimbursement for the purchase in dispute, but indicated that the enrollee was responsible for the difference between the cash price paid and the Plan's contracted/negotiated rate for the drug because the pharmacy did not automatically submit the claim(s) online to be processed by the Plan.The policy for an enrollee to be responsible for the difference between the cash price paid and the Plan's contracted/negotiated rate, for purchases made at in-network pharmacies that are not automatically run through the Plan's online claims processing system, is limited to those situations in which online claims processing is available at the time of purchase but is not utilized due to an error on the enrollee's part, such as failing to present their insurance card when one was available. Since online claims processing was unable to be utilized in this case due to an error on the Plan and/or pharmacy's part, this is a situation in which the Plan's policy of charging the enrollee the difference between the cash price paid and the Plan's contracted/negotiated rate for the drug is not applicable. The documentation shows when the Plan processed the claim $0.09 was reimbursed to the enrollee and only $1.00 was applied to the TrOOP. The enrollee paid $84.99 for the March 20, 2020 purchase. Therefore, it is our decision that the Plan is required to provide additional reimbursement for Losartan Potassium 25 mg purchased March 20, 2020. The reimbursement amount should be the total cash price paid, minus any applicable tiered copayment/coinsurance amount, and minus any reimbursement already provided only.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Shingrix received on February 12, 2020, from your physician's office. The Plan did not grant this request. We received this case to conduct an independent review.The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. The record indicates that you received Shingrix, a Medicare-covered vaccine, from your physician's office on February 12, 2020. The case record includes proof of payment showing that you have paid the bill for vaccine and its administration in full. The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to cover and provide any applicable reimbursement for Shingrix received on February 12, 2020, from your physician's office.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for the Testosterone ingredient of the Testosterone-Estradiol-Estriol-Progesterone Compound purchased February 5, 2020. The Plan did not grant this request. Wereceived this case to conduct an independent review.Medicare Part D does not cover drugs that are not FDA approved. A representative of the pharmacy statedthat the Testosterone ingredient of the Testosterone-Estradiol-Estriol-Progesterone Compound purchasedFebruary 5, 2020 is a bulk powder. Bulk powders used in pharmacy compounding are not reviewed andapproved for safety and efficacy by the FDA. Therefore, the Plan is not required to cover or providereimbursement for the Testosterone ingredient of the Testosterone-Estradiol-Estriol-ProgesteroneCompound purchased February 5, 2020.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes if payment can be made under the Medicare Part D benefit.