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

You asked the Plan to cover Butalbital/Aspirin/Caffeine, 50/325/50 mg. 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 Butalbital-Aspirin-Caffeine, 50-325-50 mg.Butalbital-Aspirin-Caffeine 50-325-50 mg is requested to treat chronic muscle spasm and migraine headaches. The diagnoses are well documented in the medical record. It is noted that the enrollee has been effectively treated with Fioricet off and on (especially the muscle spasm headaches) in combination with Diazepam and infrequent opioids. Butalbital-Aspirin-Caffeine 50-325-50 mg is not on the Plan's formulary; however generic Fioricet (butalbital/ acetaminophen/ caffeine) is on the Plan's formulary. The prescriber has not indicated why all alternatives required by the Plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are not met. Therefore, the Plan is not required to cover Butalbital/Aspirin/Caffeine, 50/325/50 mg.
Appeal type: Prescription Drug
Decision: Partially 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 us as required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Triple Antibiotic Foil Packet, Melatonin 3 mg, Vitamin D 400 units, Acetaminophen 650 mg/20.3 mL, Potassium Chloride 20 meq, Haloperidol 5 mg, Namenda 10 mg, Triamcinolone 0.5% Cream and Atenolol 25 mg received December 9, 2019 through December 12, 2019. The Plan did not grant this request. We received this case to conduct an independent review.Favorable DecisionThe Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case you were at the medical center from December 9, 2019 through December 12, 2019 for an emergency or urgent care situation. You received several self-administered drugs during this stay. You requested reimbursement from the Part D Plan. The request includes an itemized statement and proof of payment for the December 9 through December 12 stay. The Plan did not provide any evidence that the claims have been processed, nor did the Plan provide any reason why the claims should not be processed at this time. Additionally, Potassium Chloride 20 meq, Haloperidol 5 mg, Namenda 10 mg, Triamcinolone 0.5% Cream and Atenolol 25 mg are Part D eligible drugs. The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to process and provide reimbursement for Potassium Chloride 20 meq, Haloperidol 5 mg, Namenda 10 mg, Triamcinolone 0.5% Cream and Atenolol 25 mg received December 9, 2019 through December 12, 2019.Unfavorable DecisionMedicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drug's classification or determined from other available resources that Triple Antibiotic Foil Packet, Melatonin 3 mg, Vitamin D 400 units and Acetaminophen 650 mg/20.3 mL received December 9, 2019 through December 12, 2019 are non-prescription or OTC drugs. Therefore, Triple Antibiotic Foil Packet, Melatonin 3 mg, Vitamin D 400 units and Acetaminophen 650 mg/20.3 mL received December 9, 2019 through December 12, 2019 are not eligible for Part D coverage, 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 only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Amitiza, 24 mcg capsule. 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 a tiering exception for Amitiza, 24 mcg capsule.The drug is requested to treat the enrollee's condition. The drug is a brand drug on tier 3 of the Plan's formulary. There are no available lower tier brand drugs on the Plan's formulary to treat the enrollee's condition. Therefore, the drug is not eligible for a tiering exception. Our Physician Reviewer's opinion 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 the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug is being used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met because there 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 Amitiza, 24 mcg capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Erythromycin Ethylsuccinate. 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 Erythromycin Ethylsuccinate.Erythromycin Ethylsuccinate is requested for treatment of ineffective esophageal motility/dyskinesia of the esophagus, 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. 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 Erythromycin Ethylsuccinate 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 Erythromycin Ethylsuccinate. 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

You asked the Plan to provide reimbursement for Hydrocodone-Acetaminophen 7.5-325 mg purchased January 3, 2020. The Plan 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 you pay the full cost of a prescription drug out-of-pocket or if you find you have paid more than you expected to pay under the Plan's coverage rules, you can ask the Plan to pay you back. When submitting a request for reimbursement, the Plan requires that you submit your receipt documenting the payment you have made along with your reimbursement request.In this case, the enrollee purchased Hydrocodone-Acetaminophen 7.5-325 mg on January 3, 2020. The enrollee paid the full cost at the time of purchase because Hydrocodone-Acetaminophen 7.5-325 mg, for a quantity of 90 per 30 days, required an opioid prior authorization review for this enrollee. The Plan subsequently provided coverage and reimbursement for the purchase(s) in dispute, but indicated that the enrollee was responsible for the difference between the cash price paid and the Plan's contracted/negotiated rate for the drug because the pharmacy did not automatically submit the claim(s) online to be processed by the Plan.The policy for an enrollee to be responsible for the difference between the cash price paid and the Plan's contracted/negotiated rate, for purchases made at in-network pharmacies that are not automatically run through the Plan's online claims processing system, is limited to those situations in which online claims processing is available at the time of purchase but is not utilized due to an error on the enrollee's part, such as failing to present their insurance card when one was available. Since online claims processing was unable to be utilized in this case due to an error on the Plan and/or pharmacy's part, this is a situation in which the Plan's policy of charging the enrollee the difference between the cash price paid and the Plan's contracted/negotiated rate for the drug is not applicable. Therefore, it is our decision that the Plan is required to provide additional reimbursement for Hydrocodone-Acetaminophen 7.5-325 mg purchased January 3, 2020. The reimbursement amount should be the total cash price paid, minus any applicable tiered copayment/coinsurance amount, and minus any reimbursement already provided only.
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 Loratadine, Novolin N, Metformin HCL, Atorvastatin Calcium, Clopidogrel Bisulfate, Cyclobenzaprine HCL, Metoprolol Tartrate, Allopurinol, Victoza (Liraglutide), Betamethasone Dipropionate Cream and Carboxymethyl Cellulose purchased August 13, 2018 through September 18, 2019 from a VA Medical Center. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules state that coordination of benefits between Part D and VA benefits is not possible. While a beneficiary may be eligible to receive VA prescription drug benefits and enrollee in a Part D sponsor, he or she cannot use both benefits for a single prescription.In this case, you requested coverage and/or reimbursement for drugs already covered by a veteran benefit. VA benefits cannot be coordinated with Part D. In other words, Part D cannot pay for any drugs which were already paid for by a VA benefit. Thus, Loratadine, Novolin N, Metformin HCL, Atorvastatin Calcium, Clopidogrel Bisulfate, Cyclobenzaprine HCL, Metoprolol Tartrate, Allopurinol, Victoza (Liraglutide), Betamethasone Dipropionate Cream and Carboxymethyl Cellulose are not eligible for coverage or reimbursement by Part D. Therefore, it is our decision that the Plan is not required to cover or provide reimbursement for Loratadine, Novolin N, Metformin HCL, Atorvastatin Calcium, Clopidogrel Bisulfate, Cyclobenzaprine HCL, Metoprolol Tartrate, Allopurinol, Victoza (Liraglutide), Betamethasone Dipropionate Cream and Carboxymethyl Cellulose purchased August 13, 2018 through September 18, 2019 from a VA Medical Center.
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 Prednisolone 25 mg purchased July 31, 2019 from a pharmacy outside the United States. The Plan did not grant this request. We received this case to conduct an independent review.Prednisolone 25 mg purchased July 31, 2019 is not covered by Medicare because it was purchased outside the United States. Therefore, our decision is that the Part D Plan is not required to pay for Prednisolone 25 mg purchased July 31, 2019 from a pharmacy outside the United States. This decision does not concern the medical 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

You asked the Plan to cover Pregabalin, 75 mg capsule. 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 Pregabalin, 75 mg.Pregabalin, 75 mg capsule is requested for treatment of post-traumatic osteoarthritis of the knee, 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. 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 Pregabalin, 75 mg capsule 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 Pregabalin, 75 mg capsule. 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 Promacta, 50 mg tablet. 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 Promacta, 50 mg tablet.The drug is requested to treat aplastic anemia. Additional medical information was requested by the Part D QIC. The prescribing physician was asked to address the Plan's prior authorization criteria. The enrollee does not satisfy the Plan's coverage criteria. The prescriber has not sufficiently addressed the Plan's coverage criteria and/or has not indicated why all alternatives required by the Plan would likely not be as effective for the enrollee as the requested drug, and/or would likely cause adverse reaction(s) or other harm to the enrollee. Our Physician's opinion is that neither prior authorization nor prior authorization exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. A Plan must grant an exception to prior approval rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on the available documentation, our Physician Reviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is not required to cover Promacta, 50 mg tablet.
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 a tiering exception for Prazosin HCL. 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 a tiering exception for Prazosin HCL 2 mg. The drug is requested to treat the enrollee's condition. The drug is a generic drug on Tier 3 of the Plan's formulary. A request for prescriber statement was sent and not returned. The prescriber does not state why all available lower tier alternatives on the Plan's formulary to treat the enrollee's condition (1) would not be as effective for the enrollee as the requested drug and/or (2) would have adverse effects for the enrollee. Therefore, an exception to these criteria is not supported. Our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules require a Plan to grant an exception to its tiering structure whenever it determines that the higher cost-sharing tiered drug for treatment of the enrollee's condition is medically necessary consistent with the prescriber's statement. Our Physician Reviewer's opinion is that tiering exception criteria are not met. Therefore, our decision is the Plan is not required to provide a tiering exception for Prazosin HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Spiriva Handihaler. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Spiriva Handihaler. The drug is requested to treat chronic obstructive pulmonary disease. You have not indicated why all alternatives required by the Plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are not met. Therefore, the Plan is not required to cover Spiriva Handihaler.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Ingrezza 80 mg capsule, 30 capsules per 30 days. The Plan did not grant thisrequest. 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 Ingrezza 80 mg capsule, 30 capsules per 30 days. The drug is requested to treat tardive dyskinesia.Upon reconsideration, you stated that the enrollee has a history of depression and family history of suicideand as such Austedo is inappropriate for the enrollee. You have indicated why all alternatives required bythe Plan would likely not be as effective as the requested drug for the enrollee, and/or would likely causeadverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria ismedically necessary. Our Physician Reviewer's opinion is that formulary exception criteria are metA Plan must grant an exception for a drug that is not on its formulary if it determines that the requesteddrug is medically necessary, consistent with the prescriber's statement. Based on a review of the availabledocumentation, our Physician Reviewer's opinion is that formulary exception criteria are met. Therefore,the Plan is required to cover Ingrezza 80 mg capsule, 30 capsules per 30 days.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Lynparza. 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 Lynparza. The drug is requested to treat endometrial cancer, which is an off-label (non-FDA approved) use.The enrollee is a 70 year old woman with metastatic endometrial cancer involving lungs, uterus and abdominal lymph node. She has been treated with Carboplatin, Taxol and Keytruda. Her tumor has a BRCA mutation and high tumor mutational burden. The office note of January 29, 2020 states testing for germline BRCA mutation was negative. The note indicates options include Megace, Tamoxifen or Letrozole or a clinical trial or hospice. The prescriber requests Lynparza to treat her.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. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. 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 conditionFor coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. For Part D drugs used in an anticancer chemotherapeutic regimen, 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 or peer-reviewed medical literature in CMS-approved journals or publications.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia and there was no peer-reviewed literature from an approved journal submitted to support the use of Lynparza 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 Lynparza. 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.