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

You asked the Plan to cover Pregabalin 75 mg. 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 Pregabalin 75 mg. Pregabalin 75 mg is requested to treat nondiabetic polyneuropathy in an enrollee with neuralgia, neuritis, chronic inflammatory demyelinating polyneuropathy and small fiber neuropathy. The prescriber clarified the diagnosis in the request for reconsideration. Medical records from date of service were provided which support these diagnoses.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.DRUGDEX cites results from the following reference in the FDA USE section Neuropathic pain - spinal cord injury: Finnerup NB, Attal N, Haroutounian S, et al: Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol 2015; 14(2):162-173 which concluded that the requested drug is one of several drugs proposed as first line treatment of neuropathic pain in general. It is noted that the enrollee's condition is included in the patient population of studies cited.The enrollee does not satisfy the Plan's coverage criteria. However, the prescriber has indicated why all alternatives required by the Plan would likely not be as effective as the requested drug for the enrollee, and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is medically necessary. Our Physician Reviewer's opinion is that 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 met. Therefore, our decision is the Plan is required to cover Pregabalin 75 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 provide reimbursement for Irbesartan 150 mg purchased April 6, 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. The documentation submitted by the Plan included documentation which shows that they provided coverage for a 90 day supply of Irbesartan 150 on April 1, 2020. You indicate you were initially informed by the pharmacy that this fill would not be completed due to the pharmacy being out of stock. The script was then filled and mailed to you after you had made the April 6, 2020 purchase. The record does not show that you refused or returned the April 1, 2020 order. The record also shows that you were not eligible for coverage of another refill of this drug until June 3, 2020. As a result, your purchase of Irbesartan 150 mg on April 6, 2020 was a refill-too-soon. The Plan is not required to provide coverage or payment for drugs that are refilled-too-soon.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 Irbesartan 150 mg purchased April 6, 2020.
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 a tiering exception for Ventolin HFA. 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 Ventolin HFA. The drug is requested to treat asthma. The drug is a brand drug on Tier 4 of the Plan's formulary.Additional medical information was requested by the Part D QIC. The prescribing physician was asked to address the lower tier formulary alternatives. A response from the prescribing physician was not received. The prescriber does not state why all available lower tier alternatives on the Plan's formulary to treat the enrollee's condition (1) would not be as effective for the enrollee as the requested drug and/or (2) would have adverse effects for the enrollee. Therefore, an exception to these criteria is not supported. Our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules require a Plan to grant an exception to its tiering structure whenever it determines that the higher cost-sharing tiered drug for treatment of the enrollee's condition is medically necessary consistent with the prescriber's statement. Our Physician Reviewer's opinion is that tiering exception criteria are not met. Therefore, our decision is the Plan is not required to provide a tiering exception for Ventolin HFA.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for Amiodarone 200 mg purchased February 10, 2020. The Plan did not grant this request. We received this case to conduct an independent review.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. Pursuant to guidelines issued by the Centers for Medicare and Medicare Services (CMS), as of February 1, 2014, the Plan has enacted a policy in which an enrollee is responsible for the difference between the cash price paid and the Plan's contracted negotiated rate for a drug for any purchases made at an in-network pharmacy that are not submitted online electronically through the pharmacy.In this case, the Plan approved coverage for Amiodarone 200 mg purchased February 10, 2020. The Plancalculated reimbursement by using their contracted negotiated rate as the total cost for the drugs andsubtracting the required copayment amount. Thus, the Plan charged the enrollee the difference between thecash price paid and the Plan's contracted negotiated rate for this drug. The Plan is permitted to calculatereimbursement this way for in-network pharmacy purchases not run online electronically per Medicarerules.The case record indicates that the Plan provided coverage and calculated reimbursement in accordance withMedicare law and rules. Therefore, our decision is the Plan is not required to provide additionalreimbursement for Amiodarone 200 mg purchased February 10, 2020.Please note: When you purchased this drug February 10, 2020, the pharmacy did not run your Medicareinsurance. Therefore, you should reach out to the pharmacy to reconcile your claim for any additionalreimbursement you feel applicable.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for the Linezolid Compound purchased. 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 Linezolid Compound purchased. 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 Linezolid Compound purchased.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 Amitriptyline-Ketoprofen-Lidocaine 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 or would be used when compounding the prescription for Amitriptyline-Ketoprofen-Lidocaine 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 Amitriptyline-Ketoprofen-Lidocaine 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

You asked the Plan to provide a tiering exception for Fluoxetine DR 90 mg. The Plan did not grant thisrequest. 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 a tiering exception for Fluoxetine DR 90 mg. The drug is requested to treat F32.9 Major depressivedisorder, single episode, unspecified. The prescriber sent a statement clarifying the medicalhistory. The prescriber states the enrollee tried and failed or had adverse effects with Zoloft and Wellbutrin.Fluoxetine DR 90 mg is a generic drug on Tier 4 of the Plan's formulary. The prescriber does not state whyall available lower tier alternatives on the Plan's formulary to treat the enrollee's condition (1) would not beas effective for the enrollee as the requested drug and/or (2) would have adverse effects for the enrollee.Therefore, an exception to these criteria is not supported. Our Physician Reviewer's opinion is that tieringexception criteria are not met.Medicare rules require a Plan to grant an exception to its tiering structure whenever it determines that thehigher cost-sharing tiered drug for treatment of the enrollee's condition is medically necessary consistentwith the prescriber's statement. Our Physician Reviewer's opinion is that tiering exception criteria are notmet. Therefore, our decision is the Plan is not required to provide a tiering exception for Fluoxetine DR.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Cresemba. 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 Cresemba. The drug is requested for prophylaxis of infectious disease related to blastic NK cell lymphoma with pancytopenia, 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 Cresemba 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 Cresemba. 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

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 TDAP vaccine received. The Plan did not grant this request. We received this case to conduct an independent review.The Part D Plan covers certain vaccines purchased and/or administered as out-of-network. For out-of-network vaccines, the enrollee will be responsible for the difference in cost between the Plan's allowed charge for the vaccine and its administration, and the amount charged by the out-of-network provider. The documentation you submitted shows that you received the TDAP vaccine from your prescriber's office. The specific vaccine name (for example, Shingrix, Boostrix, Adacel) was not provided. The associated National Drug Code (NDC) number was also not provided. A representative from MAXIMUS Federal services contacted the prescriber's office to obtain this information. The prescriber's office was unable to provide this information. The vaccine name as well as the NDC number are required in order for the Plan to process the claim.Although you submitted proof of payment in full for the vaccine, the Plan's criteria for out-of-network coverage and reimbursement have not been met because the vaccine's name and NDC number were not provided.Therefore, our decision is the Plan is not required to cover and provide reimbursement for TDAP vaccine received at this time. For detailed information on how vaccines are reimbursed, please refer to the Plan's Evidence of Coverage.Please note: you may wish to submit the medical record and/or a statement from the prescriber's office verifying the vaccine name and the NDC. If you are only able to obtain the vaccine name and not the NDC number you should still submit that to the Plan and request they process your request.
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 Vivitrol ER. The Plan did not grant this request. We received this case toconduct an independent review.Medicare law specifically excludes coverage for any drug for which payment would be available underParts A or B of Medicare for that individual. Medicare Part B pays for services and supplies incident to theservice of a physician (or other practitioner).We requested additional medical information to determine if criteria for Medicare Part D have been met.We requested confirmation of how and where this drug is supplied and billed as well as a statementregarding the Plan's formulary alternatives. The record submitted by the Plan indicates Vivitrol ER will beadministered in the prescriber's office; however, there was no response to our request for more specificinformation regarding how the drug is supplied and billed. Vivitrol ER is a type of drug that is not usuallyself-administered. There is insufficient information to show that this drug is not eligible for Medicare PartB coverage. As a result, the record does not establish that Vivitrol ER is a Part D drug in this case.Therefore, it is our decision that the Part D Plan is not required to cover Vivitrol ER.This decision does not concern the medical necessity or appropriateness of the requested drug. It onlyestablishes if payment can be made under the Medicare Part D benefit.Please contact the Plan for more information regarding coverage of Vivitrol ER under the Part B 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 Potassium chloride packet. 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 Potassium chloride packet. Potassium chloride packet is requested to treat Hypokalemia. The prescriberwas asked questions to clarify the diagnosis being treated and to provide documentation to support thenoted diagnosis. The prescriber was also asked questions to address the Plan's coverage/formularyexception criteria. Please note that Potassium chloride oral solutions are available on the formulary. Aresponse from the prescriber was not received. Therefore, based on the current record, there is insufficientdocumentation to support an exception to the Plan's coverage criteria.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requesteddrug is medically necessary, consistent with the prescriber's statement. Based on a review of the availabledocumentation, our Physician Reviewer's opinion is that formulary exception criteria are not met.Therefore, the Plan is not required to cover Potassium chloride packet.
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 Dronabinol. 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 Dronabinol 10 mg capsule.The drug is requested to treat ICD-10 diagnosis code F43.12, Post-traumatic stress disorder, chronic, 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 Dronabinol 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 Dronabinol. 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

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 Vemlidy 25 mg. 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 Vemlidy 25 mg tablet.The drug is requested to treat chronic hepatitis B virus (HBV) infection. Additional medical information was requested by the Part D QIC. The prescribing physician was asked to address the enrollee's diagnosis and prior authorization coverage criteria. The prescriber statement was returned. The enrollee does 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 the enrollee as the requested drug, and/or would likely cause adverse reaction(s) or other harm to the enrollee.Our Physician Reviewer'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 Vemlidy.