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

At issue is Glycerin liquid bulk powder compounded drug. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The requested drug is considered a bulk powder/ or is consistent of bulk powder ingredients and is excluded from coverage under Part D. 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

At issue is Levofloxacin Hemihydrate bulk powder compounded drug. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The requested drug is considered a bulk powder/ or is consistent of bulk powder ingredients and is excluded from coverage under Part D. 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

At issue is Methylparaben bulk powder compounded drug. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The requested drug is considered a bulk powder/ or is consistent of bulk powder ingredients and is excluded from coverage under Part D. 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

At issue is Propylparaben bulk powder compounded drug. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The requested drug is considered a bulk powder/ or is consistent of bulk powder ingredients and is excluded from coverage under Part D. 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

At issue is coverage for Sterile water liquid. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. Sterile water is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Yellow Fever vaccination prescribed for an unknown diagnosis. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The submitted documentation indicates the vaccination was administered on June 26, 2023, at Wake County Clinic, Raleigh, North Carolina 27610. However, there is missing information needed to consider the request. The required information includes a legible invoice itemizing the services rendered, the National Drug Code (NDC) of the vaccine, and the prescribing physicians name and address. Therefore, the reimbursement criteria have not been met and the plan is not required to reimburse the enrollee for the cost of the services.This decision does not address the medical necessity of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Travaton Z 0.004 percent ophthalmic solution to treat ocular hypertension in enrollee with glaucoma. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that all formulary alternatives were tried and failed or were deemed contraindicated. We received additional documentation and included it in the review. The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not validate that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements have not been met.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amoxicillin/Clavulanate Potassium 875/125 milligram tablets prescribed for unspecified diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The cost of the medication is less than what the required cost-sharing amount would have been with the plan benefit. Therefore, the enrollee will not be receiving a reimbursement. The amount the enrollee paid (up to the plan allowance, if applicable) will be applied to the total out of pocket (TrOOP) expenditures that count towards the catastrophic coverage threshold. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Chlorhexidine Gluconate 0.12 percent solution prescribed for unspecified diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The cost of the medication is less than what the required cost-sharing amount would have been with the plan benefit. Therefore, the enrollee will not be receiving a reimbursement. The amount the enrollee paid (up to the plan allowance, if applicable) will be applied to the total out of pocket (TrOOP) expenditures that count towards the catastrophic coverage threshold. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ibuprofen 800 milligram tablets prescribed for unspecified diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The cost of the medication is less than what the required cost-sharing amount would have been with the plan benefit. Therefore, the enrollee will not be receiving a reimbursement. The amount the enrollee paid (up to the plan allowance, if applicable) will be applied to the total out of pocket (TrOOP) expenditures that count towards the catastrophic coverage threshold. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylprednisolone 4 milligram tablets prescribed for unspecified diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The cost of the medication is less than what the required cost-sharing amount would have been with the plan benefit. Therefore, the enrollee will not be receiving a reimbursement. The amount the enrollee paid (up to the plan allowance, if applicable) will be applied to the total out of pocket (TrOOP) expenditures that count towards the catastrophic coverage threshold. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Ketorolac 0.5 percent ophthalmic solution for dates of purchase April 18, 2023, and June 1, 2023, prescribed for an unknown condition. The Part D plan denied the enrollees request for reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the drug purchased on April 18, 2023, was refilled in too short of a timeframe. According to the plans Evidence of Coverage, limits and restrictions are placed on drugs that are refilled too soon. The enrollee would incur an out-of-pocket expense for drugs refilled too soon. We determined no reimbursement is required by the plan.The plan submitted documentation that shows the enrollee was in the initial coverage stage of the Part D benefit when this drug was purchased on June 1, 2023. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. The claim was processed correctly and applied to the initial coverage phase. We determined no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Prednisone AC 1 percent eye drop for dates of purchase April 18, 2023, and June 8, 2023, prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the requested drug was purchased on both April 18, 2023, and June 8, 2023. The plans Evidence of Coverage states that the enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Tobramycin/Dexamethasone Ophthalmic Suspension prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the requested drug was purchased. The plans Evidence of Coverage states that the enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Budesonide nebulizer solution. The Part D plan auto-forwarded the case to us for review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The documentation indicates that the requested drug is going to be used with a nebulizer in the enrollees home or home-like setting. Medicare classifies nebulizers as durable medical equipment. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment. Additionally, payment will be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment. Any drug available for coverage under Medicare Part B cannot be covered under Part D, per Medicare rules. Therefore, the requested nebulizer drug is not eligible for Medicare Part D coverage.This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit the request for coverage through Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Ipratropium Bromide/Albuterol Sulfate nebulizer solution. The Part D plan auto-forwarded the case to us for review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The documentation indicates that the requested drug is going to be used with a nebulizer in the enrollees home or home-like setting. Medicare classifies nebulizers as durable medical equipment. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment. Additionally, payment will be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment. Any drug available for coverage under Medicare Part B cannot be covered under Part D, per Medicare rules. Therefore, the requested nebulizer drug is not eligible for Medicare Part D coverage.This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit the request for coverage through Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Moxifloxacin/Bromfenac Sodium/Prednisolone Sodium bulk powder compounded drug. The Part D plan denied/auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The requested drug is considered a bulk powder/ or is consistent of bulk powder ingredients and is excluded from coverage under Part D. 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

At issue is coverage for Levothyroxine Sodium 75 microgram tablet. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The record shows the plan reprocessed claims for Levothyroxine Sodium and adjusted the amount owed due to the true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copayment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Ondansetron Hydrochloride 8 milligram tablet. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The record shows the plan reprocessed claims for Ondansetron Hydrochloride and adjusted the amount owed due to the true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copayment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Prochlorperazine Maleate 10 milligram tablet. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The record shows the plan reprocessed claims for Prochlorperazine Maleate and adjusted the amount owed due to the true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copayment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Tukysa 150 milligram tablet. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The record shows the plan reprocessed claims for Tukysa and adjusted the amount owed due to the true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copayment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Atenolol 25 milligram tablets. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Per the Oakland Unified School District benefits coverage, the enrollee's copay is $10 for a 1-30-day supply and $20 for a 31-60-day supply and $30 for a 61-100-day supply of a generic drug medication when using a local pharmacy. In the San Francisco Health Service System benefits coverage, the enrollee's copay is $5 for a 1-30-day supply and $ 10 for a 31 -60-day supply and $ 15 for a 61 -100-day supply of a generic drug medication when using a local pharmacy. Please note, Medicare Coordination of Benefit rules do not allow for a $0 copay for Part D prescriptions when members have dual coverage, the richer benefit pays. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for BD Pen Needle Mini. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Per the Oakland Unified School District benefits coverage, the enrollee's copay is $10 for a 1-30-day supply and $20 for a 31-60-day supply and $30 for a 61-100-day supply of a generic drug medication when using a local pharmacy. In the San Francisco Health Service System benefits coverage, the enrollee's copay is $5 for a 1-30-day supply and $ 10 for a 31 -60-day supply and $ 15 for a 61 -100-day supply of a generic drug medication when using a local pharmacy. Please note, Medicare Coordination of Benefit rules do not allow for a $0 copay for Part D prescriptions when members have dual coverage, the richer benefit pays. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Humulin 70/30 Kwikpen. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Per the Oakland Unified School District benefits coverage, the enrollee's copay is $10 for a 1-30-day supply and $20 for a 31-60-day supply and $30 for a 61-100-day supply of a generic drug medication when using a local pharmacy. In the San Francisco Health Service System benefits coverage, the enrollee's copay is $5 for a 1-30-day supply and $ 10 for a 31 -60-day supply and $ 15 for a 61 -100-day supply of a generic drug medication when using a local pharmacy. Please note, Medicare Coordination of Benefit rules do not allow for a $0 copay for Part D prescriptions when members have dual coverage, the richer benefit pays. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Levothyroxine 175 microgram tablets. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Per the Oakland Unified School District benefits coverage, the enrollee's copay is $10 for a 1-30-day supply and $20 for a 31-60-day supply and $30 for a 61-100-day supply of a generic drug medication when using a local pharmacy. In the San Francisco Health Service System benefits coverage, the enrollee's copay is $5 for a 1-30-day supply and $ 10 for a 31 -60-day supply and $ 15 for a 61 -100-day supply of a generic drug medication when using a local pharmacy. Please note, Medicare Coordination of Benefit rules do not allow for a $0 copay for Part D prescriptions when members have dual coverage, the richer benefit pays. Therefore, we determined that the plan is not required to provide further reimbursement.