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

You asked the Plan to provide a tiering exception for Shingrix. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tier drug is being used to treat. In this case, the Plan covers vaccines as a Tier 3 item only. There are no lower cost-sharing tier vaccines available on the Plan's formulary. Because there are no lower cost-sharing tier vaccines, Shingrix is not eligible for a tiering exception. Therefore, our decision is the Plan is not required to provide a tiering exception for Shingrix.Please note: although the tiering exception was not approved, you may wish to purchase the vaccine and have the vaccine administered at a preferred in-network pharmacy and not your prescriber's office. The prescriber's office is considered an out-of-network pharmacy and may charge more for the vaccine than the Plan's copayment amount, they may also charge for the administration of the vaccine. You may wish to discuss pharmacy options and costs with the Plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Gamunex C. The Plan did not grant this request. We received this case to conduct an independent review.Medicare law specifically excludes coverage for any drug for which payment would be available under Parts A or B of Medicare for that individual. Medicare Part B provides coverage of IVIG for the treatment of primary immune deficiency diseases (ICD-10 diagnosis codes D80.0, D80.2, D80.3, D80.4, D80.5, D80.6, D80.7, D81.0, D81.1, D81.2, D81.5, D81.6, D81.7, D81.89, D81.9, D82.0, D82.1, D82.4, D83.0, D83.1, D83.2, D83.8, D83.9, G11.3) in the home.The case record indicates that Gamunex C is prescribed for the treatment of a primary immune deficiency disease, ICD-10 D83.0 Common variable immunodeficiency with predominant abnormalities of B-cell numbers and function and will be administered in the home. It appears that this medication qualifies for coverage under Part B rather than Part D. As a result, the record does not establish that Gamunex C is a Part D drug in this case. Therefore, it is our decision that the Part D Plan is not required to provide coverage for Gamunex C {under the Part D benefit.} This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.You may wish to submit this request to the Medicare Part B Plan.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Lidocaine 5% Patch as prescribed. 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 Lidocaine 5% Patch.The drug is requested to treat back pain. Medical records were provided. DRUGDEX, a Medicare approved compendium, has listed chronic back pain, hip or knee osteoarthritis pain in their Comparative Efficacy section in the monograph for the requested drug which includes a link to the following article:Krebs EE, Gravely A, Nugent S, et al: Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA 2018; 319(9):872-882. PubMed Abstract: http://www.ncbi.nlm.nih.gov/... PubMed Article: http://www.ncbi.nlm.nih.gov/... The article states, Among patients with chronic back pain or hip or knee osteoarthritis pain, treatment with opioids compared with nonopioid medications did not result in significantly better pain related function over 12 months. Nonopioid treatment was associated with significantly better pain intensity. (i.e. less pain)For coverage under the prescription drug benefit, Medicare requires that the drug prescribed be used for a medically accepted indication. Our Physician Reviewer found that the Medicare-approved resources do contain citations to support the use of the requested drug for treatment of the noted condition. Therefore, the requested drug is being prescribed for a medically accepted indication.The enrollee satisfies the Plan's coverage criteria. Our Physician Reviewer's opinion is that prior authorization criteria are met.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 citations in the Medicare approved compendia that support the use of Lidocaine 5% Patch as prescribed for the diagnosed condition. As a result, Lidocaine 5% Patch as prescribed is being prescribed for a medically accepted indication as defined by Medicare law.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. Based on the available documentation, our Physician Reviewer's opinion is that prior approval criteria are met. Therefore, our decision is the Plan is required to cover Lidocaine 5% Patch as prescribed.Please note that if the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The health plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will notify you in writing that the case is being reviewed again and the outcome of the reopening.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Lidocaine 3% Cream. The Plan did not grant this request. We received this case to conduct an independent review.Medicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drug's classification or determined from other available resources that the drug is a non-prescription or OTC drug. Therefore, Lidocaine 3% Cream is not eligible for Part D coverage, and the Plan is not required to cover it under the Part D benefit. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Rytary ER. 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 Rytary ER. The drug is requested to treat Parkinson's disease. The drug is on Tier 4 of the Plan's formulary. There are no available lower tier brand drugs on the Plan's formulary to treat the enrollee's 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 Rytary ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Calcitonin-Salmon. The Plan did not grant this request. We received this case to conduct an independent review.Medicare law requires that all drugs and biologicals used in the treatment of ESRD or AKI be included in the ESRD PPS payment bundle, regardless of the reason why the drug is being prescribed and regardless of whether or not the drug is furnished by a dialysis facility. Drugs that are always considered ESRD and AKI-related include access management drugs, anemia management drugs, anti-infectives to treat site access infection, bone and mineral metabolism drugs and cellular management drugs.In this case, Calcitonin-Salmon is being prescribed to an enrollee who has ESRD or AKI and is on dialysis. Calcitonin-Salmon is a class of medication which is always considered ESRD or AKI-related for purposes of the Part B ESRD payment bundle. Thus, the requested drug is eligible for coverage under the Part B ESRD payment bundle, regardless of the reason why the drug is being prescribed and regardless of whether or not the drug is being furnished by a dialysis facility. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. Therefore, our decision is the Part D Plan is not required to cover Calcitonin-Salmon. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.You may wish to submit this request to the Medicare Part B carrier.
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 us as required by Medicare rules because it did not make a timely decision.You asked the Plan to cover or provide reimbursement for Atorvastatin 20 mg, Lidocaine Viscous HCL 2 mg, Hydrocodone Bitartrate/Acetaminophen 5/325 mg, Nyamyc 1000 units, Healthylax, Lisinopril 10 mg, and 40 mg, Aspirin Low Dose, Mag-Al Plus, Metoprolol Succinate 25 mg and 50 mg, Heartburn Relief Max ST, Chlorthalidone 25 mg, Acetaminophen 325 mg, Polyethylene Glycol 3350, Stimulant Laxative Plus Stool Softener and Atorvastatin 10 mg you received while you were a patient at the hospital.The Plan did not grant this request. We received this case to conduct an independent review.The Part D Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. If an enrollee must use an out-of-network pharmacy, the enrollee will generally have to pay the full cost when the prescription is filled. The enrollee may submit a request for reimbursement with proof of payment to ask the Plan to pay its share of the cost.In this case, the record shows that you were a patient at the hospital. You received Atorvastatin 20 mg, Lidocaine Viscous HCL 2 mg, Hydrocodone Bitartrate/Acetaminophen 5/325 mg, Nyamyc 1000 units, Healthylax, Lisinopril 10 mg, and 40 mg, Aspirin Low Dose, Mag-Al Plus, Metoprolol Succinate 25 mg and 50 mg, Heartburn Relief Max ST, Chlorthalidone 25 mg, Acetaminophen 325 mg, Polyethylene Glycol 3350, Stimulant Laxative Plus Stool Softener and Atorvastatin 10 mg for a medical emergency or urgent care. You submitted a request for reimbursement with a copy of an itemized hospital bill. However, the record does not include proof of payment in full of the self-administered drug portion of the bill. The Plan's criteria for out-of-network coverage and reimbursement have not been met. Therefore, our decision is the Plan is not required to cover or provide reimbursement for Atorvastatin 20 mg, Lidocaine Viscous HCL 2 mg, Hydrocodone Bitartrate/Acetaminophen 5/325 mg, Nyamyc 1000 units, Healthylax, Lisinopril 10 mg, and 40 mg, Aspirin Low Dose, Mag-Al Plus, Metoprolol Succinate 25 mg and 50 mg, Heartburn Relief Max ST, Chlorthalidone 25 mg, Acetaminophen 325 mg, Polyethylene Glycol 3350, Stimulant Laxative Plus Stool Softener and Atorvastatin 10 mg received as a patient at the hospital.
Appeal type: Prescription Drug
Decision: 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 us as required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Butalbital-Acetaminophen-Caffeine 50-325-40 mg. 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. The amount of the copayment or coinsurance will vary depending on the drug's tier and place of purchase. Butalbital-Acetaminophen-Caffeine 50-325-40 mg is on Tier 2 of the Plan's 2020 Formulary. In this case, you purchased Butalbital-Acetaminophen-Caffeine 50-325-40 mg. You requested reimbursement from the Part D Plan. The Plan did not process the request. The Plan verified the claim has not yet been processed and the Plan did not provide any reason why the claim should not be paid at this time.The case record indicates that the Plan did not provide coverage in accordance with the Part D Plan contract. Therefore, our decision is the Plan is required to process and provide reimbursement for Butalbital-Acetaminophen-Caffeine 50-325-40 mg.Please note that if the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The health plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will notify you in writing that the case is being reviewed again and the outcome of the reopening.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Butalbital-Aspirin-Caffeine-Codeine. 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 Butalbital-Aspirin-Caffeine-Codeine. The drug is requested to treat your condition. A request for prescriber statement was sent and not returned. You do not satisfy the Plan's coverage criteria. The prescriber has not sufficiently addressed the Plan's coverage criteria and/or has not indicated why all alternatives required by the Plan would likely not be as effective for you as the requested drug, and/or would likely cause adverse reaction(s) or other harm to you. Our Physician's opinion is that neither prior authorization nor prior authorization exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. A Plan must grant an exception to prior approval rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on the available documentation, our Physician Reviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is not required to cover Butalbital-Aspirin-Caffeine-Codeine.
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 us as required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for the Estradiol Compound. The Plan did not grant this request. We received this case to conduct an independent review.Medicare Part D does not cover drugs that are not FDA approved. A representative of the pharmacy stated that bulk powder was used when compounding the prescription for the Estradiol Compound. Bulk powders used in pharmacy compounding are not reviewed and approved for safety and efficacy by the FDA. Therefore, the Plan is not required to cover or provide reimbursement for the Estradiol Compound.This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can 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 us as required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Naltrexone 1.5mg, 3mg, and 4.5mg. The Plan did not grant this request. We received this case to conduct an independent review.Medicare Part D does not cover drugs that are not FDA approved. A representative of the pharmacy stated that bulk powder was used or would be used when compounding the prescription for Naltrexone 1.5mg, 3mg, and 4.5mg. Bulk powders used in pharmacy compounding are not reviewed and approved for safety and efficacy by the FDA. Therefore, the Plan is not required to cover Naltrexone 1.5mg, 3mg, and 4.5mg. This decision does not address the medical necessity or appropriateness 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 provide a tiering exception for Tradjenta. 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 Tradjenta. The drug is requested to treat diabetes. The drug is on Tier 3 of the Plan's formulary. There are no available (branded) lower tier drugs on the Plan's formulary to treat the enrollee's 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 Tradjenta.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for provide reimbursement for Aspirin 81 mg, Senna 8.6 mg, Donepezil HCL 10 mg, Quetiapine Fumarate 25 mg and Metoprolol Succinate ER 50 mg; Quetiapine Fumarate 50 mg and Memantine HCL 10 mg. The Plan did not grant this request. We received this case to conduct an independent review.    Aspirin and Senna  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 OTC drugs. Therefore, Aspirin and Senna purchased 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 only establishes that payment cannot be made under the Medicare Part D benefit. Donepezil HCL, Quetiapine Fumarate, Metoprolol Succinate ER and Memantine HCL  Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. The amount of the copayment or coinsurance will vary depending on the drug's tier and place of purchase. In this case,Donepezil HCL 10 mg and Metoprolol ER 50 mg are on the Plan's 2020 Formulary and classified as Tier 1 drugs. Tier 1 drugs require a $10 copayment for up to a 30 day supply when purchased from the pharmacy. Quetiapine Fumarate 25 mg and Memantine HCL 10 mg are on the Plan's 2020 Formulary and classified as Tier 2 drugs. Tier 2 drugs require a $20 copayment for up to a 30 day supply when purchased from the pharmacy. The Plan provided documentation that they have processed the claims for Donepezil HCL 10 mg, Quetiapine Fumarate 25 mg and Metoprolol Succinate ER 50 mg; Quetiapine Fumarate 50 mg and Memantine HCL 10 mg. Each of these claims were purchased as a 30 day supply. The record shows you paid less than the required copayment amount. The case record indicates that the Plan provided coverage in accordance with the Part D Plan contract. Therefore, our decision is the Plan is not required to provide reimbursement for Donepezil HCL 10 mg, Quetiapine Fumarate 25 mg and Metoprolol Succinate ER 50 mg; Quetiapine Fumarate 50 mg and Memantine HCL 10 mg. Please note: the record shows you are asking for written proof from the Plan proving what was paid and how much was paid for each claim. You may wish to contact the Plan for an Explanation of Benefits. Maximus Federal does not have access to the Plan's internal claim system, therefore, Maximus Federal cannot provide this information. Please contact the Plan directly for this information.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide additional reimbursement for Modafinil 200 mg purchased at the pharmacy. 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, you submitted a paid receipt for Modafinil 200 mg purchased at the pharmacy. The Plan provided reimbursement for this fill but stated that you were responsible for the difference between the cash price paid and the Plan's negotiated contract rate for the drug because the pharmacy did not automatically submit your claims online to be processed by the Plan. The Plan stated that the pharmacy is a network pharmacy. The record indicates that you purchased Modafinil 200 mg out of pocket. The policy for an enrollee to be responsible for the difference between the cash price paid and the Plan's contracted negotiated rate for a drug 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. Since you submitted a receipt showing full price for this prescription, it appears that 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 applicable. Therefore, it is our decision that the Plan is not required to provide additional reimbursement for Modafinil 200 mg purchased at the pharmacy.