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

At issue is coverage for Cresemba 186 milligram capsule to treat status post lung transplant. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Vyvgart 400 milligram per 20 milliliter injection to treat seronegative generalized myasthenia gravis, without acute exacerbation. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Nuedexta 20/10 milligram capsule to treat major depressive disorder, recurrent, mild, personal history of traumatic brain injury and generalized anxiety disorder. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The noted conditions are off-label uses for the requested drug. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. Therefore, the drug is being prescribed for non-medically accepted indications.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for lidocaine 5 percent ointment to treat osteoarthritis bilateral knees with chronic pain. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to clarify the condition being treated and to address the plan's prior authorization coverage criteria. We received additional documentation and included it in the review.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The Medicare approved compendium, includes an off-label citation for the use of the requested drug to treat chronic back pain. Therefore, the requested drug is being prescribed to treat a medically accepted indication.The plan has prior authorization requirements that must be met before coverage of this drug is provided. However, the plans prior authorization requirements are diagnosis-specific and not related to the condition being treated. Since the condition being treated is a medically accepted indication outlined in Drug Dex, an exception to the plans diagnosis-specific coverage requirements is supported. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Peptide 1.5 liquid to treat unknown diagnosis. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. Peptide 1.5 is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Syfovre 15 milligram intravitreal injection. The Part D plan denied the request for reimbursement. 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 includes a physicians itemization indicating a charge for for a Syfovre injection. Payment for a drug is required up front from the enrollee when provided at an out of network pharmacy or provider's office. The enrollee submitted documentation to the plan that includes a reimbursement request and an itemized physicians statement as receipt for payment of the drug at issue. Therefore, we determined that the plan is required to reimburse the enrollee for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin prescribed for an unknown diagnosis. The Part D plan denied/auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee filled a prescription for the requested drug at a network pharmacy. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Spikevax Vaccine vial. 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 received the vaccine at a out of network pharmacy. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or prescribers office. 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 enrollee provided a receipt from the pharmacy for the vaccine indicating full payment was made for the vaccine. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for a Meningococcal vaccination. The Part D plan auto-forwarded the case to us for reviewWe received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The submitted documentation indicates the vaccine was obtained and administered in the physicians office. However, there is missing information needed to consider the request. The required information includes the prescribing physicians name, address and National Provider Identifier (NPI) number, and the National Drug Code (NDC) of the vaccine. Therefore, the reimbursement criteria have not been met and the plan is not required to reimburse the enrollee for the cost of the services.This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for a Typhoid vaccination. The Part D plan auto-forwarded the case to us for reviewWe received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The submitted documentation indicates the vaccine was obtained and administered in the physicians office. However, there is missing information needed to consider the request. The required information includes the prescribing physicians name, address and National Provider Identifier (NPI) number, and the National Drug Code (NDC) of the vaccine. Therefore, the reimbursement criteria have not been met and the plan is not required to reimburse the enrollee for the cost of the services.This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Paracetamol 500 milligram tablet for date September 14, 2023, while on a cruise ship. The Part D plan denied the request for coverage and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The submitted documentation shows the enrollee purchased drugs on a cruise ship. Drugs purchased on a cruise ship are considered foreign claims outside of the United States and are excluded from coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Paxlovid 150 milligram/100 milligram tablet for date September 14, 2023, while on a cruise ship. The Part D plan denied the request for coverage and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The submitted documentation shows the enrollee purchased drugs on a cruise ship. Drugs purchased on a cruise ship are considered foreign claims outside of the United States and are excluded from coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prednisone 20 milligram tablet for date September 14, 2023, while on a cruise ship. The Part D plan denied the request for coverage and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The submitted documentation shows the enrollee purchased drugs on a cruise ship. Drugs purchased on a cruise ship are considered foreign claims outside of the United States and are excluded from coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a Salbutamol Inhaler 100 microgram dose for date September 14, 2023, while on a cruise ship. The Part D plan denied the request for coverage and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The submitted documentation shows the enrollee purchased drugs on a cruise ship. Drugs purchased on a cruise ship are considered foreign claims outside of the United States and are excluded from coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estring 2 milligram vaginal ring prescribed to treat enrollee's condition. The Part D plan denied the request for reimbursement and then auto forwarded the case to us for review.We received a 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 plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. The plan submitted documentation that shows paid claims on file which were paid correctly according to members benefits. Estring has an unbreakable package size; therefore, the member is responsible for the 30-day supply copay (41percent) in initial coverage, not the 90-day supply copay (30 percent). The claims paid for 2/17/2023, 5/03/2023, and 8/14/2023, were already paid at the 41percent initial coverage rate. Therefore, we determined the plan is correct in its calculation of the copay and is not required to provide additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for a compound drug, Naltrexone 3 milligram scored tablet, consisting of Naltrexone Hydrochloride and Prosolv silicified microcrystalline cellulose (SMCC) purchased on April 13, 2023, and July 12, 2023. The Part D plan denied the request for reimbursement.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We determined that the plan is not required to reimburse payment for the compound drug, Naltrexone 3 milligram scored tablet. The compound drug do not contain any Part D eligible ingredients. According to Medicare rules, drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The National Drug Code submitted for Naltrexone Hydrochloride supports this ingredient is a bulk powder and therefore, is excluded from coverage under Part D. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if reimbursement can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Estradiol 0.1 milligrams per gram cream to treat chronic urinary tract infections. The Part D plan denied the request and then auto-forwarded the case to us for review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The use of the requested drug to treat the noted condition is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug for the treatment of the noted condition. In order to be eligible for a tiering exception, the drug must be prescribed to treat a medically accepted indication. Therefore, the requested drug is not eligible for a tiering exception. 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 coverage for Lidocaine 5 percent patch for chronic pain syndrome. The Part D plan denied the request for coverage and then 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 the medication is being prescribed for a medical accepted indication and that the enrollee has satisfied the plans prior authorization coverage criteria. We received additional information and included it in the review.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Lidocaine 5 percent patch to treat chest pain. 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. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Albuterol Sulfate HFA (hydrofluoroalkane) 90 microgram per actuation aerosol to treat chronic obstructive pulmonary disease. 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.Albuterol Sulfate HFA (hydrofluoroalkane) 90 microgram per actuation aerosol 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 coverage for Wegovy 1 milligram per 0.5 milliliter solution auto injector to treat obesity. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Drugs prescribed to treat obesity and/or to promote weight loss are excluded from the Part D coverage. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Lamotrigine 200mg tablet to treat bipolar disorder, unspecified. 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.Lamotrigine is a generic drug on Tier 2 of the plans formulary. There are no generic drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. 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 a tiering exception request for Xarelto 20 milligram tablet to treat deep venous thrombosis. 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 available documentation.Xarelto is a brand drug on Tier 2 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception.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 a tiering exception request for Clenpiq 10/3.5/12 milligram per 160 milliliter oral solution for colonoscopy preparation. 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 available documentation. Clenpiq is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception.  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 a tiering exception request for Januvia 25 milligram tablet to treat the enrollee's condition. 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 available documentation. Januvia 25 milligram tablet is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception.  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 coverage for Xarelto 20 milligram tablet to treat deep vein thrombosis. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Xarelto is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. 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 coverage for Olopatadine Hydrochloride 0.1 Percent eye drops to treat meibomianitis and Hordeolum Internum, (inflamed and infected oil gland on the inner edge of eyelid). The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.