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

At issue is coverage for Doxycycline Hyclate 100 milligram oral capsule to treat tick bite and acne rosacea. 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.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that all lower-tiered drugs to treat the enrollees condition were tried and failed or were deemed contraindicated. We received additional documentation and included it in the review.Doxycycline Hyclate is a generic drug on Tier 3 of the plans formulary. The prescriber has not provided patient-specific clinical rationale as to why all of the lower-tiered alternative drugs on the plans formulary to treat the enrollees condition are contraindicated. Therefore, the tiering exception requirements have not been met. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Celecoxib 100 milligram capsules 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 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 this drug was paid correctly and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Heplisav-B vaccine. The Part D plan denied the request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the requested vaccine at their prescribers office. Based on the information provided, we determined the drug may be eligible for coverage under Medicare Part B. A drug that is covered under Part B is not eligible for coverage under Part D. Therefore, the Part D plan is not required to cover or provide reimbursement for the requested vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acetaminophen 650 milligram tablets prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.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 submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol Sulfate 2.5 milligram per 3 milliliter inhalant prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.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 submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aspirin EC 81 milligram tablet prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.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 submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Atorvastatin 40 milligram tablets prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.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 submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dextrose gel prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.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 submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diphenoxylate/Atropine 2.5/0.025 milligram tablets prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.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 submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluorescein 1 milligram strips prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.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 submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluticasone nasal spray prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.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 submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gabapentin capsules prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.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 submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Glucagon 1 milligram injection prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.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 submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Heparin 500 unit per milliliter injection prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.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 submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydralazine 10 milligram injection prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.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 submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Insulin Glargine solution prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.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 submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Insulin Lispro injection prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.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 submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ipratropium Bromide 17 microgram inhalant prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.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 submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ipratropium Bromide/Albuterol Sulfate inhalation solution prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.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 submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levothyroxine 75 microgram tablets prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.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 submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Losartan 25 milligram tablets prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.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 submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Meclizine 12.5 milligram tablets prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.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 submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.