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

You asked the Plan to cover Lidocaine 5% patch. The Plan did not grant this request. We received this caseto conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Lidocaine 5% patch. Lidocaine 5% patch is requested to treat low back pain. For coverage under theprescription drug benefit, Medicare requires that the drug prescribed be used for a medically acceptedindication. DRUGDEX, a Medicare approved compendium, has listed chronic back pain, hip or kneeosteoarthritis pain in their Comparative Efficacy section in the monograph for the requested drug whichincludes a link to the following article: Krebs EE, Gravely A, Nugent S, et al: Effect of opioid vsnonopioid medications on pain-related function in patients with chronic back pain or hip or kneeosteoarthritis pain: the SPACE randomized clinical trial. JAMA 2018; 319(9):872-882.PubMed Abstract: http://www.ncbi.nlm.nih.gov/...PubMed Article: http://www.ncbi.nlm.nih.gov/...The article states, Among patients with chronic back pain or hip or knee osteoarthritis pain, treatment withopioids compared with nonopioid medications did not result in significantly better pain related functionover 12 months. Nonopioid treatment was associated with significantly better pain intensity. (i.e. less pain)Our Physician Reviewer found that the Medicare-approved resources do contain citations to support the useof the requested drug for treatment of the noted condition. Therefore, the requested drug is being prescribedfor a medically accepted indication. The enrollee is unable to take Acetaminophen due to liver disease, isunable to take NSAID's due to a history of GI bleeding and is unable to take opioids due to age and risk offalling. The enrollee does not satisfy the Plan's coverage criteria. You have indicated why all alternativesrequired by the Plan would likely not be as effective as the requested drug for the enrollee, and/or wouldlikely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan'scoverage criteria is medically necessary. Our Physician Reviewer's opinion is that prior authorizationexception criteria are met.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 reviewedthis file and determined that there are citations in the Medicare approved compendia that support the use ofLidocaine 5% patch for the diagnosed condition. As a result, Lidocaine 5% patch is being prescribed for amedically accepted indication as defined by Medicare law.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs.Based on the available documentation, our Physician Reviewer's opinion is that prior approval criteria aremet. Therefore, our decision is the Plan is required to cover Lidocaine 5% patch.
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 Velphoro. 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 Velphoro. The drug is requested to treat hyperphosphatemia with end stage renal disease on dialysis.You do not satisfy the Plan's coverage criteria. The prescriber has not sufficiently addressed the Plan'scoverage criteria (documentation that you have tried and failed or are intolerant to maximum tolerabledoses of sevelamer carbonate and lanthanum carbonate) and/or has not indicated why all alternativesrequired by the Plan would likely not be as effective for you as the requested drug, and/or would likelycause adverse reaction(s) or other harm to you. Our Physician's opinion is that neither prior authorizationnor 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 Velphoro.
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 Brilinta 90 mg purchased May 6, 2020. The Plan did notgrant this request. We received this case to conduct an independent review.In this case, the records show that when Brilinta 90 mg was purchased on May 6, 2020, the claim straddledboth the deductible stage and the initial coverage stage of the Part D benefit. An enrollee is responsible forthe full cost of covered drugs until the deductible amount $195 is satisfied. The initial coverage phaserequires a $37 copayment amount for this drug and day supply purchased. The Plan documentation showsthat the total cost of the drug was 388.01. The record shows that there was $195 remaining in the deductiblephase of coverage. This amount is subtracted from the total cost of the drug. This left a remaining total drugcost owed of $193.01. This remaining balance was subject to the initial coverage stage copayment amount,which is $37. The total of the two figures owed during each benefit phase (deductible and initial coverage)is $232. 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 Brilinta 90 mg purchased May 6, 2020was applied to your yearly 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 Brilinta 90 mgpurchased May 6, 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 usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Promethazine HCL. The Plan did not grant this request. We received this caseto conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Promethazine HCL. The drug is requested to treat R11.2 Nausea with vomiting, unspecified, which isan off-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. 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 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 Promethazine HCL 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, itcannot be covered under the Medicare Part D benefit for this condition. An exceptions request based onmedical necessity cannot be considered because this drug, as prescribed, does not meet the definition of aMedicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage forPromethazine HCL.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 Acetaminophen 325 mg and Docusate Sodium 100 mgreceived January 28, 2020 and January 29, 2020. The Plan did not grant this request. We received this caseto conduct an independent review.Medicare 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 OTCdrugs. Therefore, Acetaminophen 325 mg and Docusate Sodium 100 mg are not eligible for Part Dcoverage, 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 onlyestablishes 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 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 December 16, 2019. ThePlan 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 enrolleepays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof ofpayment to ask the Plan to pay its share of the cost. The Plan required a $37 copayment amount for up to a30 day supply of a Tier 3 drug purchased in 2019 from a preferred retail pharmacy. The Shingrix vaccinewas on the Plan's 2019 formulary and was classified as a Tier 3 drug. A request for reimbursement wassubmitted to the Plan. In this case, the Plan provided documentation showing that this claim was coveredby the Plan at the time of purchase. The record shows that the Shingrix vaccine received December 16,2019 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 the Shingrix vaccinereceived December 16, 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 cover or provide reimbursement for self-administered drugs received from January25 through January 30, 2020, while a patient at the hospital. The Plan did not grant this request. Wereceived this case to conduct an independent review.The Part D Plan covers prescriptions filled at an out-of-network pharmacy only in certain limitedcircumstances. If an enrollee must use an out-of-network pharmacy, the enrollee will generally have to paythe full cost when the prescription is filled. The enrollee may submit a request for reimbursement withproof of payment to ask the Plan to pay its share of the cost.In this case, the record shows that you were a patient at the hospital from January 25 through January 30,2020. You received self-administered drugs for a medical emergency or urgent care. You submitted arequest for reimbursement with proof of payment. However, the record does not include an itemizedstatement that identifies the self-administered drugs you received. The Plan's criteria for out-of-networkcoverage and reimbursement have not been met. Therefore, our decision is the Plan is not required to coveror provide reimbursement for self-administered drugs received January 25 through January 30, 2020, whilea patient at the hospital.
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 Ondansetron HCL 4 mg purchased February 28, 2020. 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 Ondansetron HCL. Ondansetron HCL is requested to treat nausea and vomiting in this adult enrollee, which is an off-label (non-FDA approved) use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition in adults. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because 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 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 Ondansetron HCL 4 mg 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 or reimbursement for Ondansetron HCL 4 mg purchased February 28, 2020. 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 Cevimeline. 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 Cevimeline. The drug is requested to treat xerostomia/dry mouth due to age and edentulous state, whichis an off-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. Additionalmedical information was requested by the Part D QIC. The prescribing physician was asked to address theformulary alternatives and to clarify your diagnosis. The prescribing physician states that yourxerostomia/dry mouth is due to old age and edentulous. Therefore, the requested drug is not beingprescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions requestbased on medical necessity cannot be considered because the requested drug, as prescribed, does not meetthe definition 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 Cevimeline 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 Cevimeline.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

You asked the Plan to provide a tiering exception for Prolia 60 mg/mL. 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 requestfor a tiering exception for Prolia.The drug is requested to treat the enrollee's condition. The drug is a biologic, branded drug on tier 4 of thePlan's formulary. There are no available lower tier biologic drugs on the Plan's formulary to treat theenrollee's condition. Therefore, the drug is not eligible for a tiering exception. Our Physician Reviewer'sopinion 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 thesame type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in alower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug isbeing used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met becausethere 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 Prolia 60 mg/mL.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Tretinoin 0.025% cream. 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 Tretinoin 0.025% cream.The drug is requested to treat geographic tongue, which is an off-label (non-FDA approved) use. The prescriber sent a letter dated 6/17/2020 clarifying the diagnosis. Medical records were provided from date of service 6/11/2020. The medical records document that Tretinoin 0.025% topical cream is being prescribed to be applied topically every evening for geographic tongue. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because 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 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 Tretinoin 0.025% cream 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 Tretinoin 0.025% cream. 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: 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 usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for the Tenivac vaccine and its administration fee receivedMarch 2, 2020. 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 Tenivac vaccine (National Drug Code (NDC) 49281-215-88) from yourprescriber's office. You requested reimbursement from the Part D Plan. The Plan did not process therequest. Tenivac is a Part D eligible vaccine. A representative from MAXIMUS Federal verified the NDC,the vaccine was administered as a routine injection and that the vaccine and its administration fee has beenpaid for in full. The Plan's out-of-network coverage rules were followed. Therefore, our decision is thePlan is required to provide coverage for the Tenivac vaccine and its administration fee received March 2,2020 from your prescriber's office.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Premarin. The Plan did not grant this request. Wereceived this case to conduct an independent review.Medicare rules do not require the Part D plan to grant a tiering exception for a brand or biologic drug of thesame type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) ifthe lower tier(s) on the formulary only contain(s) generic alternative drugs. Premarin is a Tier 3 brand drug.The lower cost-sharing tier(s) only contain(s) generic alternative drugs. Therefore, our decision is the Planis not required to provide a tiering exception for Premarin.