Persius/hicric huggingface dataset:
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 Shingrix purchased on November 7, 2019, and January 25, 2020, from the pharmacy. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the Plan to pay its share of the cost. The Plan required a $45 copayment for up to a 30-day supply of a Tier 3 drug purchased from a standard retail pharmacy in 2019 and 2020. A request for reimbursement was submitted to the Plan. In this case, the Plan provided documentation showing that this claim was covered by the Plan at the time of purchase. The record shows that Shingrix was purchased for an amount that is less than or equal to the required copayment amount. The case record indicates that the Plan provided coverage in accordance with the Part D contract. Therefore, our decision is the Plan is not required to provide reimbursement for Shingrix purchased on November 7, 2019, and January 25, 2020, from the pharmacy.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Duexis, 800/26.6 mg tablet. 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 Duexis 800/26.6 mg tablet.The drug is requested to treat the enrollee's condition. The prescriber has not indicated why 2 H2/NSAIDcombination alternatives required by the Plan (Cimetidine, Famotidine, Ibuprofen, Meloxicam, andNaproxen) would likely not be as effective for the enrollee as the requested drug; and/or would likely causeadverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria isnot supported. 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 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 Duexis, 800/26.6 mg tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Xeljanz XR. 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 Xeljanz XR 11 mg tablet. The drug is requested to treat psoriatic arthritis. The prescriber stated that therequested drug will not be used in combination with a non-biologic DMARD. The enrollee does not satisfythe Plan's coverage criteria. The prescriber has not sufficiently addressed the Plan's coverage criteria and/orhas not indicated why all alternatives required by the Plan would likely not be as effective for the enrolleeas the requested drug, and/or would likely cause adverse reaction(s) or other harm to the enrollee. OurPhysician'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. APlan must grant an exception to prior approval rules if it determines that the requested drug is medicallynecessary, consistent with the prescriber's statement. Based on the available documentation, our PhysicianReviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is notrequired to cover Xeljanz XR.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Lunesta. The Plan did not grant this request. We received this case to conductan independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Lunesta 2 mg tablet.The drug is requested to treat insomnia. The prescriber has not indicated why all alternatives required bythe Plan (Belsomra) would likely not be as effective for the enrollee as the requested drug; and/or wouldlikely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan'scoverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria arenot met.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 Lunesta.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Xifaxan, 550 mg. 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 Xifaxan, 550 mg.The drug is requested to treat abdominal distention from small intestine bacterial overgrowth, which is anoff-label (non-FDA approved) use. The Medicare-approved compendia do not contain any citations tosupport the use of the requested drug, as prescribed, for treatment of the noted condition. Uponreconsideration request, the prescriber's office stated that the enrollee has irritable bowel diarrheapredominant. The medical records submitted contradict this statement and support the above noteddiagnosis. Therefore, the requested drug is not being prescribed for a medically accepted indication asdefined by Medicare law. As such, an exceptions request based on medical necessity cannot be consideredbecause 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 acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Xifaxan, 550 mg tablet for the diagnosed condition. As aresult, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. Assuch, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions requestbased on medical necessity cannot be considered because this drug, as prescribed, does not meet thedefinition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to providecoverage for Xifaxan, 550 mg tablet.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan 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 usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover and provide reimbursement for Dulcolax and Lansoprazole purchased onMarch 26, 2020, from the pharmacy. The Plan did not grant this request. We received this case to conductan independent review.Medicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drugs'classification or determined from other available resources that the drugs are non-prescription or OTCdrugs. Therefore, Dulcolax and Lansoprazole are not eligible for Part D coverage, and the Plan is notrequired to cover them under the Part D benefit.This decision does not address the medical necessity or appropriateness of the requested drugs. It onlyestablishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for Enoxaparin Inj purchased April 8, 2020 from thepharmacy. The Plan did not grant this request. We received this case to conduct an independent review.In this case, the records show that when Enoxaparin Inj was purchased on April 8, 2020, the claimstraddled both the deductible stage and the initial coverage stage of the Part D benefit. An enrollee isresponsible for the full cost of covered drugs until the deductible amount $375 is satisfied. The initialcoverage phase requires a 38% amount for this drug and day supply purchased. The Plan documentationalso shows that there was $208.92 remaining in the deductible phase of coverage. This amount is subtractedfrom the total cost of the drug. This left a remaining total drug cost owed of $763.48. This remainingbalance was subject to the initial coverage stage 38% amount. 38% of the remaining balance is $290.12.The total of the two figures owed during each benefit phase (deductible and initial coverage) is $499.04.The record shows that the enrollee was charged an amount that is less than or equal to the requiredcopayment for each phase the claim was processed in. The cost of Enoxaparin Inj was applied to youryearly true out-of-pocket (TrOOP) costs.The case record indicates that the Plan provided coverage in accordance with the Part D Plan contract.Therefore, the Plan is not required to provide additional payment and/or reimbursement for Enoxaparin Inj.
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 the Magic Mouthwash Compound purchased March 20,2019. 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 statedthat bulk powder was used when compounding the prescription for the Magic Mouthwash Compoundpurchased March 20, 2019. Bulk powders used in pharmacy compounding are not reviewed and approvedfor safety and efficacy by the FDA. Therefore, the Plan is not required to cover or provide reimbursementfor the Magic Mouthwash Compound purchased March 20, 2019.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes 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 usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for the Shingrix vaccine received July 3, 2019 and October31, 2019. 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. In this case,documentation in the record shows that the enrollee was in the deductible stage when the Shingrix vaccinewas received on July 3, 2019 and October 31, 2019. During the deductible stage, the Plan requires that theenrollee pay the full cost of Tier 3, Tier 4 and Tier 5 drugs purchased in 2019 before the Plan would pay ashare of the cost. The Shingrix vaccine was on the Plan's 2019 formulary and was classified as a Tier 3drug. The Plan provided documentation showing that this claim was covered by the Plan at the time ofpurchase, and that the full cost of the purchase in dispute was applied to the required deductible amount.The case record indicates that the Plan provided coverage in accordance with the Part D Plan contract.Therefore, our decision is the Plan is not required to provide reimbursement for the Shingrix vaccinereceived July 3, 2019 and October 31, 2019.
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 the TDAP vaccine and its administration fee receivedFebruary 24, 2020. The Plan did not grant this request. We received this case to conduct an independentreview.Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. The amount ofthe copayment or coinsurance will vary depending on the drug's tier and place of purchase. In this case, thedocumentation provided shows you were administered the TDAP vaccine from the clinic. You requestedreimbursement from the Part D Plan. The Plan denied the request on the basis that the National Drug Code(NDC) associated with the TDAP vaccine was not provided. A representative from MAXIMUS Federalservices made attempts to obtain the NDC from the clinic but the attempts were unsuccessful. The NDC isrequired for the Plan to process reimbursement. Therefore, our decision is the Plan is not required toprovide reimbursement for the TDAP vaccine and its administration fee received February 24, 2020 at thistime.Please note: you may wish to contact the clinic that administered the vaccine on February 24, 2020 andrequest they provide you with the NDC associated with the TDAP vaccine you received. Once you receivethat information you may wish to submit it to the Plan and request they process your claim.
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 and provide reimbursement for Fluorouracil-Calcipotriene compoundpurchased on March 9, 2020, from your compounding pharmacy. The Plan did not grant this request. Wereceived this case to conduct an independent review.Medicare Part D does not cover drugs that are not FDA approved. A representative of the compoundingpharmacy stated that bulk powder was used or would be used when compounding the prescription forFluorouracil-Calcipotriene compound. Bulk powders used in pharmacy compounding are not reviewed andapproved for safety and efficacy by the FDA. Therefore, the Plan is not required to cover or providereimbursement for Fluorouracil-Calcipotriene compound.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Gabapentin. 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 Gabapentin 600 mg tablet.The drug is requested to treat hemicrania continua, which is an off-label (non-FDA approved) use. TheMedicare-approved compendia do not contain any citations to support the use of the requested drug, asprescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for amedically accepted indication as defined by Medicare law. As such, an exceptions request based onmedical necessity cannot be considered because the requested drug, as prescribed, does not meet thedefinition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage underMedicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Gabapentin for the diagnosed condition. As a result, the drug isnot being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot becovered under the Medicare Part D benefit for this condition. An exceptions request based on medicalnecessity cannot be considered because this drug, as prescribed, does not meet the definition of a MedicarePart D drug. Therefore, our decision is that the Plan is not required to provide coverage for Gabapentin.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Partially Favorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Bisacodyl 10 mg, Indomethacin 50 mg, Docusate Sodium 100 mg, Aspirin 81 mg and Daily Multi Vitamin received March 6, 2019 through March 8, 2019. The Plan did not grant this request. We received this case to conduct an independent review.IndomethacinThe Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, you received Indomethacin 50 mg while at the hospital in March 2020. Indomethacin 50 mg (42211-0102-43) is a Part D eligible drug. Proof of payment has been established. The Plan denied the request on the basis that prior authorization was not obtained. Because this was a hospital stay, you were not in a position to obtain the drugs that had been previously filled at a network pharmacy, nor were they able to obtain prior authorization or off-formulary exception review. Since this was a one-time emergency stay, the Plan should provide an exception to their normal coverage rules. The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to provide coverage and reimbursement for Indomethacin 50 mg received while at the hospital from March 6, 2019 through March 8, 2019.Bisacodyl, Docusate Sodium, Aspirin and Daily Multi VitaminMedicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drugs' classifications or determined from other available resources that the drugs are non-prescription or OTC drugs. Therefore, Bisacodyl, Docusate Sodium, Aspirin and Daily Multi Vitamin received March 6, 2019 through March 8, 2019 are not eligible for Part D coverage, and the Plan is not required to cover or provide reimbursement for them under the Part D benefit.This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
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 Leflunomide. 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 Leflunomide 10 mg tablet. The drug is requested to treat the enrollee's condition. The drug is a generic drug on tier 3 of the Plan's formulary. There are no available lower tier drugs on the Plan's formulary to treat the enrollee's condition. Therefore, the drug is not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of the same type 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 Leflunomide.
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 the Benzalkonium Chloride and Oxytocin ingredients ofthe Benzalkonium Chloride-Oxytocin Compound purchased March 6, 2020. The Plan did not grant thisrequest. 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 statedthat bulk ingredients were used when compounding the prescription for the Benzalkonium Chloride-Oxytocin Compound purchased March 6, 2020. Bulk ingredients used in pharmacy compounding are notreviewed and approved for safety and efficacy by the FDA. Therefore, the Plan is not required to cover orprovide reimbursement for the Benzalkonium Chloride and Oxytocin ingredients of the BenzalkoniumChloride-Oxytocin Compound purchased March 6, 2020.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes if payment can be made under the Medicare Part D benefit.