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

At issue is Levothyroxine Sodium 25 microgram tablet. 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.The submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metoprolol Tartrate 25 milligram tablet. 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.The submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Potassium Chloride ER (Extended Release) 10 milliequivalent tablet. 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.The submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tamoxifen Citrate 20 milligram tablet. 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.The submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Terconazole 0.4 percent vaginal cream. 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.The submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Terconazole 0.8 percent vaginal cream. 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.The submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Warfarin Sodium 1 milligram tablet. 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.The submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Xeromin 50 units to treat enrollee's condition. 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.The documentation indicates that the requested drug was purchased from the prescriber. Any drug available for coverage under Medicare Part B cannot be covered under Part D, per Medicare rules. Therefore, the requested drug is not eligible for 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. Please submit the request for coverage through Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prednisolone Acetate preservative free bulk powder compounded drug prescribed to treat the enrollee's condition. 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.Drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The requested drug is considered a bulk powder/ or is consistent of bulk powder ingredients and 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 payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Alprazolam 0.5 milligram tablet. 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.The record shows a drug discount was applied to the purchase. These discount coupons are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When you decided to use the drug discount, you acknowledged and agreed that the drug discount service will be treated as the primary payor with respect to the medications that you have selected to purchase through the discount program. Therefore, the plan is not required to cover or provide reimbursement for Alprazolam. To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance, without applying the discount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Desvenlafaxine 100 milligram tablet. 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.The record shows a drug discount was applied to the purchase. These discount coupons are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When you decided to use the drug discount, you acknowledged and agreed that the drug discount service will be treated as the primary payor with respect to the medications that you have selected to purchase through the discount program. Therefore, the plan is not required to cover or provide reimbursement for Desvenlafaxine. To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance, without applying the discount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Fluticasone Propionate 50 microgram nasal spray. 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.The record shows a drug discount was applied to the purchase. These discount coupons are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When you decided to use the drug discount, you acknowledged and agreed that the drug discount service will be treated as the primary payor with respect to the medications that you have selected to purchase through the discount program. Therefore, the plan is not required to cover or provide reimbursement for Fluticasone Propionate. To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance, without applying the discount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Hydrocodone/Acetaminophen 10 milligram/325 milligram tablet. 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.The record shows a drug discount was applied to the purchase. These discount coupons are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When you decided to use the drug discount, you acknowledged and agreed that the drug discount service will be treated as the primary payor with respect to the medications that you have selected to purchase through the discount program. Therefore, the plan is not required to cover or provide reimbursement for Hydrocodone/Acetaminophen. To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance, without applying the discount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Levothyroxine 125 microgram tablet. 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.The record shows a drug discount was applied to the purchase. These discount coupons are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When you decided to use the drug discount, you acknowledged and agreed that the drug discount service will be treated as the primary payor with respect to the medications that you have selected to purchase through the discount program. Therefore, the plan is not required to cover or provide reimbursement for Levothyroxine. To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance, without applying the discount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Methocarbamol 750 milligram tablet. 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.The record shows a drug discount was applied to the purchase. These discount coupons are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When you decided to use the drug discount, you acknowledged and agreed that the drug discount service will be treated as the primary payor with respect to the medications that you have selected to purchase through the discount program. Therefore, the plan is not required to cover or provide reimbursement for Methocarbamol. To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance, without applying the discount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Pantoprazole 40 milligram tablet. 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.The record shows a drug discount was applied to the purchase. These discount coupons are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When you decided to use the drug discount, you acknowledged and agreed that the drug discount service will be treated as the primary payor with respect to the medications that you have selected to purchase through the discount program. Therefore, the plan is not required to cover or provide reimbursement for Pantoprazole. To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance, without applying the discount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Potassium Chloride ER (Extended Release) 10 milliequivalent tablet. 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.The record shows a drug discount was applied to the purchase. These discount coupons are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When you decided to use the drug discount, you acknowledged and agreed that the drug discount service will be treated as the primary payor with respect to the medications that you have selected to purchase through the discount program. Therefore, the plan is not required to cover or provide reimbursement for Potassium Chloride ER. To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance, without applying the discount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Simvastatin 80 milligram tablet. 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.The record shows a drug discount was applied to the purchase. These discount coupons are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When you decided to use the drug discount, you acknowledged and agreed that the drug discount service will be treated as the primary payor with respect to the medications that you have selected to purchase through the discount program. Therefore, the plan is not required to cover or provide reimbursement for Simvastatin. To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance, without applying the discount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Spironolactone 100 milligram tablet. 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.The record shows a drug discount was applied to the purchase. These discount coupons are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When you decided to use the drug discount, you acknowledged and agreed that the drug discount service will be treated as the primary payor with respect to the medications that you have selected to purchase through the discount program. Therefore, the plan is not required to cover or provide reimbursement for Spironolactone. To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance, without applying the discount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Trazodone 50 milligram tablet. 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.The record shows a drug discount was applied to the purchase. These discount coupons are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When you decided to use the drug discount, you acknowledged and agreed that the drug discount service will be treated as the primary payor with respect to the medications that you have selected to purchase through the discount program. Therefore, the plan is not required to cover or provide reimbursement for Trazodone. To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance, without applying the discount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Triamterene/Hydrochlorothiazide 37.5 milligram tablet. 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.The record shows a drug discount was applied to the purchase. These discount coupons are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When you decided to use the drug discount, you acknowledged and agreed that the drug discount service will be treated as the primary payor with respect to the medications that you have selected to purchase through the discount program. Therefore, the plan is not required to cover or provide reimbursement for Triamterene/Hydrochlorothiazide. To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance, without applying the discount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Albuterol Hydrofluoroalkane (HFA) 90 microgram per actuation inhaler to treat the enrollees condition. 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 documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The plan provided claim information for the enrollee indicating the drug at issue was dispensed at a pharmacy not in the plans network on the date the prescription was filled. In these instances, the enrollee may be responsible for paying the difference between what he/she pays for the drug at the out of network pharmacy and the cost that the plan would cover at an in network pharmacy. The documentation does not support an extreme emergency that would require the drug be immediately supplied and the drug could have been received from a network pharmacy. Therefore, the requested drug is not eligible for Medicare Part D coverage.This decision does not address the medical necessity of the requested 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 Amoxicillin 875 milligram tablet to treat the enrollees condition. 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 documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The plan provided claim information for the enrollee indicating the drug at issue was dispensed at a pharmacy not in the plans network on the date the prescription was filled. In these instances, the enrollee may be responsible for paying the difference between what he/she pays for the drug at the out of network pharmacy and the cost that the plan would cover at an in network pharmacy. The documentation does not support an extreme emergency that would require the drug be immediately supplied and the drug could have been received from a network pharmacy. Therefore, the requested drug is not eligible for Medicare Part D coverage.This decision does not address the medical necessity of the requested 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 Azithromycin i gram powder packet to treat the enrollees condition. The Part D plan auto forwarded the case to us for review.iWe received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The plan provided claim information for the enrollee indicating the drug at issue was dispensed at a pharmacy not in the plans network on the date the prescription was filled. In these instances, the enrollee may be responsible for paying the difference between what he/she pays for the drug at the out of network pharmacy and the cost that the plan would cover at an in network pharmacy. The documentation does not support an extreme emergency that would require the drug be immediately supplied and the drug could have been received from a network pharmacy. Therefore, the requested drug is not eligible for Medicare Part D coverage.This decision does not address the medical necessity of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.