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

At issue is Azithromycin 500 milligram prescribed for an unspecified diagnosis. The Part D plan 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, including the case file from the plan, and any information submitted at the reconsideration level. Drugs furnished Incident To a physicians service are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hepatitis B (Engerix) 1 milliliter vaccine injection. The Part D plan auto-forwarded the reimbursement request.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 shows the enrollee received the requested vaccine at their prescribers office. Based on the information provided, we determined the drug may be eligible for coverage under Medicare Part B. A drug that is covered under Part B is not eligible for coverage under Part D. Therefore, the Part D plan is not required to cover or provide reimbursement for the requested vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is C-Estradiol 0.1 milligram per gram bulk powder compounded drug prescribed to treat the enrollees condition. The Part D plan 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 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 a compound drug Nifedipine and Lidocaine 0.2 percent/5 percent ointment. The case was auto-forwarded by the plan. 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 also researched Medicare regulations and Medicare approved compendia. Bulk powders do not satisfy the definition of a Part D drug. The National Drug Codes submitted for the ingredients Nifedipine USP and Lidocaine USP are bulk powder identifiers. Only compounds that contain at least one ingredient that independently meets the definition of a Part D drug, and that do not contain any ingredients covered under Part B as prescribed and dispensed or administered, may be covered under Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tetanus vaccine. The Part D plan auto-forwarded the case.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Medicare Part B covers the requested vaccine when it is administered to prevent infection as a result of an injury or wound. The submitted documentation does not provide evidence to support that the enrollee did not receive the vaccination to prevent infection of a wound. Therefore, the Part D plan is not required to cover or provide reimbursement for the requested vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is TDAP vaccine. The case was auto-forwarded by the plan.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 shows the enrollee received the requested vaccine at their prescribers office. Based on the information provided, we determined the drug may be eligible for coverage under Medicare Part B. A drug that is covered under Part B is not eligible for coverage under Part D. Therefore, the Part D plan is not required to cover or provide reimbursement for the requested vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brimonidine/Timolol 0.2/0.5 percent drops prescribed for an unspecified diagnosis. The case was auto-forwarded by the plan.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 requested the Part D plan to provide reimbursement for the requested drug purchased on October 6, 2022. However, there is missing information needed to consider the request. The required information should include the National Drug Code (NDC) of the requested drug and the prescribing physicians name, address and National Provider Identifier (NPI) number. Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix vaccine and administration fee prescribed for vaccination. 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 includes a request for reimbursement. 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 or physician's statement showing the amount that was paid by the enrollee was not provided. In addition, the name of the vaccine/drug was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Shingrix vaccine and administration prescribed for prophylaxis. The case was auto-forwarded by the plan.We performed an independent and de novo review. We reviewed all documentation submitted. The record shows the enrollee is over 50 years of age and received the Shingrix vaccine. Proof of payment was submitted.We determined that the plan is required to reimburse you for the Shingrix vaccine and administration.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Microcrystal Cellulose powder. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows the Microcrystal Cellulose powder is part of a compounded drug and each ingredient is reviewed individually. Medicare Part D does not cover drugs that do not meet the definition of a Part D drug. None of the ingredients within the compounded drug are eligible for Part D coverage. Therefore, we determined that the plan is not required to cover or reimburse for the Microcrystal Cellulose powder compounded drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Thyroid 90 milligram powder. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows the Thyroid 90 milligram powder is part of a compounded drug and each ingredient is reviewed individually. Medicare Part D does not cover drugs that do not meet the definition of a Part D drug. None of the ingredients within the compounded drug are eligible for Part D coverage. Therefore, we determined that the plan is not required to cover or reimburse for the Thyroid 90 milligram powder compounded drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 5 milligram tablet to treat erectile dysfunction. The case was auto-forwarded by the plan.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee has satisfied the plans prior authorization coverage criteria. We received additional documentation and included it in the review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other diagnoses for which the drug is not Food and Drug Administration (FDA) approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sublocade 300 milligram per 1.5 milliliter injection to treat opioid dependence. 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 documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness 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 Tenivac 2 limit of flocculation per 0.5-milliliter/5 limit of flocculation per 0.5-milliliter for routine prevention of tetanus and diphtheria. 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 documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The documentation satisfies the plans coverage criteria. The prescriber states the vaccine was given as a routine booster and not due to injury or illness.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 Tretinoin 0.1 percent cream to treat age related skin changes and wrinkles in an enrollee who does not have acne. 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 documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria. 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 Potassium Citrate extended release 10 milliequivalents tablet prescribed for the treatment and prevention of kidney stones. 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 documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.Potassium Citrate extended release 10 milliequivalents tablet is a generic drug on Tier 4 of the plans formulary. There are no generic drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alprazolam 0.25 milligram tablet prescribed for an unspecified diagnosis. 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 documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. 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, there is evidence to support that the plan issued a recovery notice within 45 days of the plans receipt of complete information regarding the claims adjustment. Therefore, the enrollee is responsible for their share of any copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alprazolam 0.5 milligram tablet prescribed for an unspecified diagnosis. 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 documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. 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, there is evidence to support that the plan issued a recovery notice within 45 days of the plans receipt of complete information regarding the claims adjustment. Therefore, the enrollee is responsible for their share of any copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dicyclomine Hydrochloride 20 milligram tablet prescribed for an unspecified diagnosis. 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 documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. 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, there is evidence to support that the plan issued a recovery notice within 45 days of the plans receipt of complete information regarding the claims adjustment. Therefore, the enrollee is responsible for their share of any copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluticasone 50 microgram prescribed for an unspecified diagnosis. 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 documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. 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, there is evidence to support that the plan issued a recovery notice within 45 days of the plans receipt of complete information regarding the claims adjustment. Therefore, the enrollee is responsible for their share of any copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Linzess 145 milligram capsule prescribed for an unspecified diagnosis. 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 documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. 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, there is evidence to support that the plan issued a recovery notice within 45 days of the plans receipt of complete information regarding the claims adjustment. Therefore, the enrollee is responsible for their share of any copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Acid delayed release prescribed for an unspecified diagnosis. 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 documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. 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, there is evidence to support that the plan issued a recovery notice within 45 days of the plans receipt of complete information regarding the claims adjustment. Therefore, the enrollee is responsible for their share of any copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Polyethylene Glycol 3350 prescribed for an unspecified diagnosis. 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 documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. 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, there is evidence to support that the plan issued a recovery notice within 45 days of the plans receipt of complete information regarding the claims adjustment. Therefore, the enrollee is responsible for their share of any copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pravastatin Sodium 20 milligram tablet prescribed for an unspecified diagnosis. 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 documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. 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, there is evidence to support that the plan issued a recovery notice within 45 days of the plans receipt of complete information regarding the claims adjustment. Therefore, the enrollee is responsible for their share of any copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ranitidine Hydrochloride 15 milligram per milliliter syrup prescribed for an unspecified diagnosis. 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 documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. 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, there is evidence to support that the plan issued a recovery notice within 45 days of the plans receipt of complete information regarding the claims adjustment. Therefore, the enrollee is responsible for their share of any copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tacrolimus 1 milligram capsule prescribed for an unspecified diagnosis. 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 documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. 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, there is evidence to support that the plan issued a recovery notice within 45 days of the plans receipt of complete information, regarding the claims adjustment. Therefore, the enrollee is responsible for their share of any copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xarelto 20 milligram tablet to treat the enrollee's condition. The Part D plan 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, including the case file from the plan, and any information submitted at the reconsideration level. Xarelto 20 milligram tablet is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception. A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Wegovy .25 milligrams per 0.5 milliliters pen injector to treat obesity. 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 documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed to treat weight gain (promote weight loss) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.