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

You asked the Plan to cover and provide reimbursement for Clindamycin HCL 300 mg purchased February 19, 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 amount of the copayment or coinsurance will vary depending on the drug's tier and place of purchase. In this case, the documentation shows the pharmacy incorrectly used a different insurance to cover this claim. The pharmacy did not use your Part D insurance. This was not an error of the Plan, this was an error of the pharmacy. Therefore, our decision is the Plan is not required to cover or provide reimbursement for Clindamycin HCL 300 mg purchased February 19, 2020.Please note: you may wish to ask to the pharmacy to re-run the claim using your Part D insurance. Until the pharmacy re-runs the claim using the Part D Plan as your insurance the Pan is not required to cover or provide reimbursement for this claim. Once the pharmacy has re-run the claim you may wish to ask for a receipt and contact the Plan.
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 Codeine-Paracetamol and Oseltamivir received November 22, 2019 while you were aboard a cruise ship . The Plan did not grant this request. We received this case to conduct an independent review.Codeine-Paracetamol and Oseltamivir received November 22, 2019 while you were aboard a cruise ship are not covered by Medicare because they were purchased outside the United States. Therefore, our decision is that the Part D Plan is not required to pay for Codeine-Paracetamol and Oseltamivir received November 22, 2019 while you were aboard a cruise ship. This decision does not concern the medical 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 cover Nurtec ODT. 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 Nurtec ODT 75 mg. Nurtec ODT is requested to treat acute migraine headache. The prescriber sent a letter dated 5/8/2020 stating that the enrollee has tried and failed Tylenol, Ibuprofen, Zolmitriptan, Naratriptan, Rizatriptan, Sumatriptan, Fioricet, and Ubrelvy. Nurtec ODT is not on the Plan's formulary. The prescriber was asked questions to clarify the diagnosis being treated and/or to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the Plan's coverage/exception criteria. A response from the prescriber was not received. Therefore, based on the current record, there is insufficient documentation to support an exception to the Plan's coverage criteria.CMS publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap discount agreement. In this case, at the time of the Plan's decision, the manufacturer for Nurtec ODT was not on this list. As of May 1, 2020 the manufacturer was on the list. Therefore, the request is eligible for coverage under Medicare Part D and we sent the request to our physician reviewer to review for coverage under Medicare Part D.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 Nurtec ODT 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 Nurtec ODT. 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 provide a tiering exception for Renacidin . The Plan did not grant this request. We received this case to conduct an independent review.Medicare law and Plan rules do not allow tiering exceptions for non-formulary drugs being covered through a formulary exception. The documentation in the record shows that Renacidin is currently being covered for the enrollee through a formulary exception. Therefore, our decision is the Plan is not required to provide a tiering exception for Renacidin.
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 Albuterol Sulfate HFA purchased at your pharmacy onMarch 13, 2020. The Plan did not grant this request. We received this case to conduct an independentreview.Medicare rules state that an individual that meets requirements under Medicare's low income subsidy (LIS)rules is entitled to a reduction or elimination in the premium, a reduction or elimination in the annualdeductible, a reduction in cost-sharing for all covered Part D drugs below the out-of-pocket limit, and areduction or elimination in cost-sharing for covered Part D drugs above the out-of-pocket limit. The extentof reduction in these benefits depends on an individual's income and resources. According to enrollmentrecords from the Centers for Medicare & Medicaid Services (CMS), you were determined to be entitled toa low-income subsidy (LIS), copay level 2, effective January 2020 through current. For copay level 2, in2020 an enrollee is required to pay $1.30 for generic drugs and $3.90 for brand drugs.In this case, you submitted a request for reimbursement for Albuterol Sulfate HFA purchased March 31,2020. During this time you were determined to be entitled to a low-income subsidy (LIS), copay level 2.We reviewed your request for reimbursement and your copayment for the requested drug. The recordshows that this claim was purchased for an amount that is less than or equal to the required LIS copaymentamount.The case record indicates that the Plan provided coverage in accordance with the Part D Plan contract andwith the LIS benefit to which you were entitled. Therefore, our decision is the Plan is not required toprovide reimbursement for Albuterol Sulfate HFA purchased March 31, 2020 at your pharmacy.
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 Oseltamivir received November 22, 2019 while aboard a cruise ship . The Plan did not grant this request. We received this case to conduct an independent review.Oseltamivir received November 22, 2019 while aboard a cruise ship is not covered by Medicare because it was purchased outside the United States. Therefore, our decision is that the Part D Plan is not required to pay for Oseltamivir received November 22, 2019 while aboard a cruise ship. This decision does not concern the medical 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 cover Levalbuterol HCL neb sol. The Plan did not grant this request. We receivedthis case to conduct an independent review.Medicare law specifically excludes coverage for any drug for which payment would be available under PartA or Part B of Medicare for that individual. Medicare Part B may pay for supplies necessary for theeffective use of durable medical equipment, including drugs and biologicals which must be put directly intothe equipment in order to achieve the therapeutic benefit of the durable medical equipment. Medicare PartB local policy states that a small volume nebulizer and related compressor are covered when medicallynecessary to administer Levalbuterol HCL neb sol for the management of obstructive pulmonary disease.In this case, the record shows that Levalbuterol HCL neb sol is administered through a nebulizer in thehome for a diagnosis of J45.909 - chronic asthma. There is no indication that it is not administered througha small volume nebulizer. It appears that this medication is eligible for coverage under Part B rather thanPart D. Drugs which are eligible for coverage under Part B are excluded from Part D coverage by Medicarelaw. Therefore, it is our decision that the Part D Plan is not required to cover Levalbuterol HCL neb sol.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.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 usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Senokot F Tab, Electrolit Nar Mand Liq, Electrolit Fresa Kiwi BTL, ElectrolitLiq Pina, Electrolit Liq Lima Limon, Electrolit Liq Mora Azul, Omeprazole, Clopidrogel, Pramigel Sus,Rapix RD, Neo Melubrina IM, Tramacet and Ciproflox purchased December 18, 2019 through January 12,2020 while you were outside the United States. The Plan did not grant this request. We received this case to conduct anindependent review.Senokot F Tab, Electrolit Nar Mand Liq, Electrolit Fresa Kiwi BTL, Electrolit Liq Pina, Electrolit LiqLima Limon, Electrolit Liq Mora Azul, Omeprazole, Clopidrogel, Pramigel Sus, Rapix RD, Neo MelubrinaIM, Tramacet and Ciproflox purchased December 18, 2019 through January 12, 2020 while you were outside the United States are not covered by Medicare because they were purchased outside the United States. Therefore, ourdecision is that the Part D Plan is not required to pay for Senokot F Tab, Electrolit Nar Mand Liq, ElectrolitFresa Kiwi BTL, Electrolit Liq Pina, Electrolit Liq Lima Limon, Electrolit Liq Mora Azul, Omeprazole,Clopidrogel, Pramigel Sus, Rapix RD, Neo Melubrina IM, Tramacet and Ciproflox purchased December18, 2019 through January 12, 2020 while you were outside the United States. This decision does not concern the medical appropriateness of the requested drug. It only establishes ifpayment 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 Xeroflam, Gudcef, Dental ER and CBCT Maxilla Sectional received February 3, 2020 through February 6, 2020 while you were outside the United States The Plan did not grant this request. We received this case to conduct an independent review.Xeroflam, Gudcef, Dental ER and CBCT Maxilla Sectional received February 3, 2020 through February 6, 2020 are not covered by Medicare because they were purchased outside the United States. Therefore, our decision is that the Part D Plan is not required to pay for Xeroflam, Gudcef, Dental ER and CBCT Maxilla Sectional received February 3, 2020 through February 6, 2020 while outside the United States. This decision does not concern the medical appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover and provide applicable reimbursement for TDAP vaccine administered by your physician on January 7, 2020. 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. In this case, the record shows you received the TDAP vaccine at your physician's office on January 7, 2020. You then requested reimbursement for the vaccine. The Plan denied coverage on the basis that the National Drug Code (NDC) number was either missing or invalid. Upon request to MAXIMUS, you have provided a valid NDC number 58160-842-11. This NDC has been checked with Medicare approved sources. TDAP (Boostrix) vaccine is on Tier 3 of the Plan's 2020 Formulary. The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to process the claim and provide applicable reimbursement for TDAP vaccine administered by your physician on January 7, 2020.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Synthroid. 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 Synthroid 50 mcg tablet. Synthroid 50 mcg tablet is requested to treat the enrollee's condition. There was insufficient documentation to substantiate that the requested drug is being used to treat the stated condition. The prescriber was asked questions to clarify the diagnosis being treated and/or to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the Plan's coverage/exception criteria. A response from the prescriber was not received. Therefore, based on the current record, there is insufficient documentation to support an exception to the Plan's coverage criteria.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of the same type 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 Synthroid.
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 Cardizem LA. The Plan did not grant this request. We received this case toconduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Cardizem LA 180 mg tablet. Cardizem LA 180 mg tablet is requested to treat hypertension. There wasinsufficient documentation to substantiate that the requested drug is being used to treat the stated condition.The prescriber was asked questions to clarify the diagnosis being treated and to provide documentation tosupport the noted diagnosis. The prescriber was also asked questions to address the Plan'scoverage/exception criteria. A response from the prescriber was not received. Therefore, based on thecurrent record, there is insufficient documentation 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 Cardizem LA.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Tadalafil 5 mg tablet. The Plan did not grant this request. We received this case to conduct an independent review.We asked a Physician Reviewer to determine whether the Plan was correct in denying the request for Tadalafil, which is not on the Plan's formulary. Our Physician Reviewer needed additional information from the prescriber to make this determination. The prescriber was asked to address whether the drugs offered by the Plan would: (1) not be as effective as the requested non-formulary drug; and/or (2) have adverse effects. The requested information was not received. Based on a review of the available documentation, 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 Tadalafil.
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 Farxiga. 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 Farxiga 10 mg tablet. Farxiga 10 mg tablet is requested to treat Type 2 diabetes mellitus. There was insufficient documentation to substantiate that the requested drug is being used to treat the stated condition. The prescriber was asked questions to clarify the diagnosis being treated and/or to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the Plan's coverage/exception criteria. A response from the prescriber was not received. Therefore, based on the current record, there is insufficient documentation 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 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 Farxiga.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Fluorouracil 2.5 gm/50 ml solution. The Plan did not grant this request. We received this case to conduct an independent review.We asked a Physician Reviewer to determine whether the Plan was correct in denying the request for Fluorouracil 2.5 gm/50 ml solution, which is not on the Plan's formulary. Our Physician Reviewer needed additional information from the prescriber to make this determination. The prescriber was asked to address whether the drugs offered by the Plan would: (1) not be as effective as the requested non-formulary drug; and/or (2) have adverse effects. The requested information was not received. Based on a review of the available documentation, 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 Fluorouracil 2.5 gm/50 ml solution.
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 cover and provide applicable reimbursement for Shingrix Vaccine and its administration administered by your physician on January 6, 2020. 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. In this case, the record shows you received the Shingrix Vaccine on January 6, 2020 at your physician's office. You then submitted a request to the Plan for reimbursement of the vaccine and its administration. Shingrix Vaccine is a Tier 3 drug on the Plan's 2020 Formulary. The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to process applicable reimbursement for Shingrix Vaccine and its administration administered by your physician on January 6, 2020.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Wixela. 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 Wixela 250 mcg/50 mcg. The drug is requested to treat asthma. 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 Wixela.