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

At issue is Lidocaine 4 percent patch. 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 prescribed that are available Over the Counter 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 Methocarbamol 500 milligram tablet to treat an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged to the enrollee at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is RX 1537840. 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 requested the plan to provide reimbursement for RX 1537840. The plan's Evidence of Coverage states, that if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, there is missing information needed to consider the request. The documentation provided includes a receipt. The documentation does not include the drug name, drug dosage, quantity of drug, the National Drug Code (NDC), and the prescribing physicians name, address, and National Provider Identifier (NPI) number. Therefore, we determined that the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix vaccine injection prescribed for vaccination. 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 vaccine was provided by the prescriber and administered in the prescribers office. The plan's Evidence of Coverage states, that 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. However, proof of payment by the enrollee in the form of a receipt was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Apixaban 5 milligram tablet. The Part D plan auto-forwarded the request.We requested 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 reimbursement request form, hospital statement, and receipt for the requested drug. However, the National Drug Code (NDC) for the drug is missing. Medicare rules state that drug claims must include a valid NDC that is listed with the Food and Drug Administration (FDA). Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Atorvastatin 40 milligram tablet. The Part D plan auto-forwarded the request.We requested 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 reimbursement request form, hospital statement, and receipt for the requested drug. However, the National Drug Code (NDC) for the drug is missing. Medicare rules state that drug claims must include a valid NDC that is listed with the Food and Drug Administration (FDA). Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Baclofen 20 milligram tablet. The Part D plan auto-forwarded the request.We requested 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 reimbursement request form, hospital statement, and receipt for the requested drug. However, the National Drug Code (NDC) for the drug is missing. Medicare rules state that drug claims must include a valid NDC that is listed with the Food and Drug Administration (FDA). Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carvedilol 3.125 milligram tablet. The Part D plan auto-forwarded the request.We requested 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 reimbursement request form, hospital statement, and receipt for the requested drug. However, the National Drug Code (NDC) for the drug is missing. Medicare rules state that drug claims must include a valid NDC that is listed with the Food and Drug Administration (FDA). Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carvedilol 6.25 milligram tablet. The Part D plan auto-forwarded the request.We requested 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 reimbursement request form, hospital statement, and receipt for the requested drug. However, the National Drug Code (NDC) for the drug is missing. Medicare rules state that drug claims must include a valid NDC that is listed with the Food and Drug Administration (FDA). Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gabapentin 600 milligram tablet. The Part D plan auto-forwarded the request.We requested 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 reimbursement request form, hospital statement, and receipt for the requested drug. However, the National Drug Code (NDC) for the drug is missing. Medicare rules state that drug claims must include a valid NDC that is listed with the Food and Drug Administration (FDA). Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydralazine 10 milligram tablet. The Part D plan auto-forwarded the request.We requested 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 reimbursement request form, hospital statement, and receipt for the requested drug. However, the National Drug Code (NDC) for the drug is missing. Medicare rules state that drug claims must include a valid NDC that is listed with the Food and Drug Administration (FDA). Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrochlorothiazide 12.5 milligram tablet. The Part D plan auto-forwarded the request.We requested 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 reimbursement request form, hospital statement, and receipt for the requested drug. However, the National Drug Code (NDC) for the drug is missing. Medicare rules state that drug claims must include a valid NDC that is listed with the Food and Drug Administration (FDA). Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrochlorothiazide 25 milligram tablet. The Part D plan auto-forwarded the request.We requested 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 reimbursement request form, hospital statement, and receipt for the requested drug. However, the National Drug Code (NDC) for the drug is missing. Medicare rules state that drug claims must include a valid NDC that is listed with the Food and Drug Administration (FDA). Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Insulin Aspart 100 unit per 3 milliliter pen. The Part D plan auto-forwarded the request.We requested 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 reimbursement request form, hospital statement, and receipt for the requested drug. However, the National Drug Code (NDC) for the drug is missing. Medicare rules state that drug claims must include a valid NDC that is listed with the Food and Drug Administration (FDA). Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Losartan 100 milligram tablet. The Part D plan auto-forwarded the request.We requested 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 reimbursement request form, hospital statement, and receipt for the requested drug. However, the National Drug Code (NDC) for the drug is missing. Medicare rules state that drug claims must include a valid NDC that is listed with the Food and Drug Administration (FDA). Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Losartan 50 milligram tablet. The Part D plan auto-forwarded the request.We requested 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 reimbursement request form, hospital statement, and receipt for the requested drug. However, the National Drug Code (NDC) for the drug is missing. Medicare rules state that drug claims must include a valid NDC that is listed with the Food and Drug Administration (FDA). Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pantoprazole 40 milligram tablet. The Part D plan auto-forwarded the request.We requested 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 reimbursement request form, hospital statement, and receipt for the requested drug. However, the National Drug Code (NDC) for the drug is missing. Medicare rules state that drug claims must include a valid NDC that is listed with the Food and Drug Administration (FDA). Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Polyethylene Glycol and Electrolytes solution. 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 prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ropinirole 0.25 milligram tablet. The Part D plan auto-forwarded the request.We requested 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 reimbursement request form, hospital statement, and receipt for the requested drug. However, the National Drug Code (NDC) for the drug is missing. Medicare rules state that drug claims must include a valid NDC that is listed with the Food and Drug Administration (FDA). Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ticagrelor 90 milligram tablet. The Part D plan auto-forwarded the request.We requested 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 reimbursement request form, hospital statement, and receipt for the requested drug. However, the National Drug Code (NDC) for the drug is missing. Medicare rules state that drug claims must include a valid NDC that is listed with the Food and Drug Administration (FDA). Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tramadol 50 milligram tablet. The Part D plan auto-forwarded the request.We requested 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 reimbursement request form, hospital statement, and receipt for the requested drug. However, the National Drug Code (NDC) for the drug is missing. Medicare rules state that drug claims must include a valid NDC that is listed with the Food and Drug Administration (FDA). Therefore, the reimbursement criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine 10 milligram tablet prescribed for chronic musculoskeletal pain/spasm. 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 use of the requested drug to treat the provided diagnosis 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 diagnosis. Therefore, the requested drug is not eligible for coverage under Medicare Part D. This decision does not speak to the medical necessity of this drug; it speaks to whether the Part D drug plan is responsible for payment under the Centers for Medicare and Medicaid Services (CMS) rules.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 Ozempic 0.25 or 0.5 milligrams solution in auto injector to promote weight loss. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxychloroquine Sulfate 200 milligram tablet to treat Sjogren syndrome with keratoconjunctivitis. 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 use of the requested drug to treat the provided diagnosis 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 diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D. 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 Meperidine 50 milligram per 5 milliliter solution to treat complex regional pain syndrome, osteoarthritis bilateral knees and left shoulder. 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 use of the requested drug to treat the provided diagnosis 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 diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.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 Omeprazole delayed release capsule 20 milligram, 120 per 30 days to treat gastroesophageal reflux disease without esophagitis. The Part D plan denied the request for this quantity of medication.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 plan limits the amount of Omeprazole delayed release capsule 20 milligram to 30 per 30 days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the diagnosis or would be likely to cause harm.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage. Therefore, an exception to the plans coverage criteria is not supported.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trelegy Ellipta 100-62.5-25microgram (mcg) per actuation aerosol to treat idiopathic pulmonary fibrosis. 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.Trelegy Ellipta 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 coverage for Synthroid 100 microgram tablet to treat hypothyroidism. 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 requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary, Euthyrox, Levoxyl, and Unithroid, would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not indicate that the enrollee has tried and failed the noted formulary alternative drugs. As such, the formulary exception criteria have not been met.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 Lidocaine 5 percent ointment, not prescribed for topical anesthesia. 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 use of the requested drug to treat the provided diagnosis 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 diagnosis. Therefore, the requested drug is not eligible for coverage under Medicare Part D. This decision does not speak to the medical necessity of this drug; it speaks to whether the Part D drug plan is responsible for payment under the Centers for Medicare and Medicaid Services (CMS) rules.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 Wegovy 0.25 milligram per 0.5 milliliter pen injection 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 5 milligram tablets to treat erectile dysfunction. 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. 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.