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 cover Advair Diskus. 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 Advair Diskus 500-50 mcg.Advair Diskus 500-50 mcg is requested to treat an unknown diagnosis. The prescriber was asked to state the enrollee's diagnosis, because there was no prescriber statement of the enrollee's diagnosis in the case file. The prescriber was also asked to address medical necessity for the requested drug. A response from the prescriber was not received. Therefore, based on the current record, there is insufficient documentation that the requested medication is being prescribed for a medically accepted indication as defined by Medicare law. In addition, an exceptions request based on medical necessity cannot be considered because it cannot be confirmed that the drug meets the definition of a Medicare Part D drug.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 needed additional information from the prescriber to determine whether the enrollee is using Advair Diskus for an FDA-approved use, or a use listed in the Medicare-approved compendia. The requested information was not received. As a result, we could not confirm that the drug is being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit. An exceptions request based on medical necessity cannot be considered because it cannot be confirmed that the drug meets the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Advair Diskus. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Atorvastatin purchased on January 4 and February 3, 2018; and January 8 and February 4, 2019, from the pharmacy. The Plan did not grant this request. We received this case to conduct an independent review.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 annual deductible, a reduction in cost-sharing for all covered Part D drugs below the out-of-pocket limit, and a reduction or elimination in cost-sharing for covered Part D drugs above the out-of-pocket limit. The extent of reduction in these benefits depends on an individual's income and resources. According to enrollment records from CMS, you were determined to be entitled to an LIS, copay level 2, effective January 1, 2018, through December 31, 2018, and January 1, 2019, through December 31, 2019. For copay level 2, an enrollee was required to pay $1.25 for generic drugs and $3.70 for brand drugs in 2018 and $1.25 for generic drugs and $3.80 for brand drugs in 2019. In this case, the case record shows that Atorvastatin was purchased for an amount that is less than or equal to the required LIS copayment amount. The case record indicates that the Plan provided coverage in accordance with the Part D Plan contract and with the LIS benefit to which you were entitled. Therefore, our decision is the Plan is not required to provide reimbursement for Atorvastatin purchased January 4 and February 3, 2018; and January 8 and February 4, 2019, from the pharmacy. The Plan was also asked to provide payment for Atorvastatin purchased January 10 and February 27, 2017. The Plan did not grant this request. We received this case to conduct an independent review. Medicare law requires that Part D Plans coordinate benefits with SPAPs, other entities providing prescription drug coverage, beneficiaries, and others paying on the beneficiaries' behalf for a period of 3 years from the date on which the prescription for a covered Part D drug was filled. This means that claims for coverage and reimbursement must be submitted to the Plan within 3 years from the date of purchase. In this case, the record shows that the purchase(s) in dispute were made in January and February 2017. A request for coverage/reimbursement was not submitted to the Plan until May 6, 2020. As a result, the claim was not submitted within the Medicare required timeframe of 3 years or less from the date the drug was filled. Therefore, our decision is that the Plan is not required to cover or provide reimbursement for Atorvastatin purchased January 10 and February 27, 2017, from the 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 usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Butalbital-Acetaminophen-Caffeine. The Plan did not grant this request. Wereceived this case to conduct an independent review.We asked a Physician Reviewer to determine whether the Plan was correct in denying the request forButalbital-Acetaminophen-Caffeine, which is subject to prior approval. Our Physician Reviewer neededadditional information from the prescriber to make this determination. The prescriber was asked to addresswhether the drugs offered by the Plan for the treatment of the enrollee's condition would: (1) not be aseffective as the requested drug; and/or (2) have adverse effects. The requested information was notreceived. Based on a review of the available documentation, neither prior authorization criteria nor priorauthorization 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 Butalbital-Acetaminophen-Caffeine.
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 Budesonide purchased from December 31, 2019, to January 2, 2020, whileaboard a cruise ship. The Plan did not grant this request. We received this case to conduct an independentreview.Budesonide is not covered by Medicare because it was purchased outside the United States. Therefore, ourdecision is that the Part D Plan is not required to pay for Budesonide.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: Favorable

You asked the Plan to provide reimbursement the Twinrix vaccine and Typhim VI vaccine receivedDecember 11, 2018. The Plan did not grant this request. We received this case to conduct an independentreview.The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances.In this case, you received the Twinrix and Typhim VI vaccines from your prescriber's office. Yourequested reimbursement from the Part D Plan. The request includes proof of payment for the two vaccines.The Plan denied the request on the basis that the National Drug Code (NDC) for each vaccine was notprovided. The Reconsideration request includes each applicable NDC (Twinrix vaccine (58160-815-52)and Typhim VI vaccine (49281-790-20)). The Twinrix vaccine (58160-815-52) and Typhim VI vaccine(49281-790-20) are Part D eligible vaccines/NDCs. The Plan's out-of-network coverage rules werefollowed. Therefore, our decision is the Plan is required to provide coverage and reimbursement for theTwinrix vaccine and Typhim VI vaccine received December 11, 2018.
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 Latanoprost purchased on December 13, 2019, while traveling outside the United States. ThePlan did not grant this request. We received this case to conduct an independent review.Latanoprost is not covered by Medicare because it was purchased outside the United States. Therefore, ourdecision is that the Part D Plan is not required to pay for Latanoprost.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

You asked the Plan to cover Corlanor. 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 Corlanor 5 mg.The drug is requested to treat inappropriate sinus tachycardia/postural orthostatic hypotension, which areoff-label (non-FDA approved) uses. The Medicare-approved compendia do not contain any citations tosupport the use of the requested drug, as prescribed, for treatment of the noted conditions. Therefore, therequested drug is not being prescribed for a medically accepted indication as defined by Medicare law. Assuch, an exceptions request based on medical necessity cannot be considered because the requested drug, asprescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is noteligible for coverage under Medicare Part D for the noted conditions.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 Corlanor for the diagnosed conditions. 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 these conditions. 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 Corlanor.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 provide reimbursement for Guaifenesin, Methylprednisolone, Acetylcysteine, SalineMist Spray, Deep Sea Nasal Spray and Amoxicillin received December 31, 2019 through January 2, 2020while aboard a cruise ship. The Plan did not grant this request. We received this case to conduct anindependent review.Guaifenesin, Methylprednisolone, Acetylcysteine, Saline Mist Spray, Deep Sea Nasal Spray andAmoxicillin received December 31, 2019 through January 2, 2020 while aboard a cruise ship are notcovered by Medicare because they were purchased outside the United States. Therefore, our decision is thatthe Part D Plan is not required to pay for Guaifenesin, Methylprednisolone, Acetylcysteine, Saline MistSpray, Deep Sea Nasal Spray and Amoxicillin received December 31, 2019 through January 2, 2020 whileaboard a cruise ship.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

You asked the Plan to provide reimbursement for Oxycontin ER 10 mg drug purchased April 13, 2020. ThePlan 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 requestfor Oxycontin ER 10 mg. The drug is requested to treat chronic pain. The prescriber has not indicated whyall alternatives required by the Plan would likely not be as effective for the enrollee as the requested drug;and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to thePlan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exceptioncriteria 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 or provide reimbursement for Oxycontin ER 10 mg drugpurchased April 13, 2020.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Plavix. 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 Plavix.Plavix is requested to treat an unknown diagnosis. The prescriber was asked to state your diagnosis, because there was no prescriber statement of your diagnosis in the case file. The prescriber was also asked to address medical necessity for the requested drug. A response from the prescriber was not received. Therefore, based on the current record, there is insufficient documentation that the requested medication is being prescribed for a medically accepted indication as defined by Medicare law. In addition, an exceptions request based on medical necessity cannot be considered because it cannot be confirmed that the drug meets the definition of a Medicare Part D drug.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 Plavix 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 Plavix. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Testosterone 20.25 mg/act (1.62%) gel. 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 Testosterone 20.25 mg/act (1.62%) gel. Testosterone 20.25 mg/act (1.62%) gel is requested to treat an unknown diagnosis. The prescriber was asked to state your diagnosis, because there was no prescriber statement of your diagnosis in the case file. The prescriber was also asked to address medical necessity for the requested drug and to address the Plan's prior authorization criteria. A response from the prescriber was not received. Therefore, based on the current record, there is insufficient documentation that the requested medication is being prescribed for a medically accepted indication as defined by Medicare law. In addition, an exceptions request based on medical necessity cannot be considered because it cannot be confirmed that the drug meets the definition of a Medicare Part D drug.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 Testosterone 20.25 mg/act (1.62%) gel 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 Testosterone 20.25 mg/act (1.62%) gel. 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 cover Zolpidem Tartrate. 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 Zolpidem Tartrate. The drug is requested to treat an unknown diagnosis. The prescriber was asked to state your diagnosis, because there was no prescriber statement of your diagnosis in the case file. The prescriber was also asked to address medical necessity for the requested drug and to address the Plan's prior authorization criteria. A response from the prescriber was not received. Therefore, based on the current record, there is insufficient documentation that the requested medication is being prescribed for a medically accepted indication as defined by Medicare law. In addition, an exceptions request based on medical necessity cannot be considered because it cannot be confirmed that the drug meets the definition of a Medicare Part D drug.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 Zolpidem Tartrate 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 Zolpidem Tartrate. 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 cover Spiriva HandiHaler. 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 Spiriva HandiHaler. This 75 year old enrollee is requesting reimbursement for Spiriva HandiHaler 18 mcg purchased December 31, 2019 at 5:30 pm. The enrollee states that he was treated for bacterial pneumonia at the hospital from December 27 - 31, 2019; upon discharge, the enrollee states that he filled several prescriptions including one for the requested drug. The enrollee states that he was informed that because of the holiday, it would take several days to get approval; however because he was still having great difficulty breathing, the enrollee filled the prescription and paid out of pocket for it. The Plan indicated that they requested information from the prescriber; however no response was received. The prescriber has not indicated why all alternatives required by the Plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not 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 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 Spiriva HandiHaler.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to provide reimbursement for the Tenivac vaccine and its administration fee received December 4, 2019. 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, you received the Tenivac vaccine from your prescriber's office on December 4, 2019. You requested reimbursement from the Part D Plan. The Plan denied the request on the basis that proof of payment for the vaccine and its administration fee was not provided. The Reconsideration appeal request submitted to MAXIMUS Federal includes proof of payment in full for the vaccine and its administration fee. The Tenivac vaccine is a Part D eligible vaccine. The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to provide coverage and reimbursement for the Tenivac vaccine and its administration fee received December 4, 2019 from the prescribers office.