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

You asked the Plan to provide a tiering exception for Dipyridamole. 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 Dipyridamole. The drug is requested to treat transient ischemic attack, prophylaxis. The drug is a generic drug on tier four of the Plan's formulary. 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 Dipyridamole.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Imatinib. 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 Imatinib 100 mg.The drug is requested to treat graft versus host disease, 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 Imatinib 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 Imatinib. 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 cover Humira CF 40 mg/0.4 mL. 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 Humira pen 40 mg/0.4 mL. The drug is requested to treat rheumatoid arthritis. On 04/30/2020 the prescriber sent additional information clarifying the diagnosis and addressing the Plan's coverage criteria - the patient has previously tried and failed Methotrexate from August 2014 through February 2015. The enrollee satisfies the Plan's coverage criteria. Our Physician Reviewer's opinion is that prior authorization criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. Based on the available documentation, our Physician Reviewer's opinion is that prior approval criteria are met. Therefore, our decision is the Plan is required to cover Humira CF 40 mg/0.4 mL.Please note that if the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The health plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will notify you in writing that the case is being reviewed again and the outcome of the reopening.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to provide reimbursement for Valacyclovir HCL 1 gm purchased February 23, 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 Valacyclovir HCL 1 gm on February 23, 2020. The enrollee paid the full cost at the time of purchase because the pharmacy did not run the claim through the enrollee's Part D benefit. The Plan subsequently provided coverage and reimbursement for the purchase 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 Plan states the enrollee should contact the pharmacy to obtain the reimbursement.However, 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. The enrollee presented their benefit card at the time of purchase, but the Plan failed to run the claim electronically. Since online claims processing was unable to be utilized in this case due to an error on the 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 Valacyclovir HCL 1 gm purchased February 23, 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.Please note that if the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The health plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will notify you in writing that the case is being reviewed again and the outcome of the reopening.
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 cover Lidocaine 5% ointment. 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 Lidocaine 5% ointment.The drug is requested to treat pain from post-herpetic neuralgia 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 formulation, 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 Lidocaine 5% ointment 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 Lidocaine 5% ointment.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 Monurol. 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 Monurol. The drug is requested for urinary tract infection, prophylaxis, 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 (prophylaxis of urinary tract infection). 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 Monurol 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 Monurol. 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 provide a tiering exception for Fentanyl Patch. The Plan did not grant this request. We received this case to conduct an independent review.Medicare law and Plan rules do not allow tiering exceptions for non-formulary drugs being covered through a formulary exception. The documentation in the record shows that Fentanyl Patch is currently being covered for the enrollee through a formulary exception. Therefore, our decision is the Plan is not required to provide a tiering exception for Fentanyl Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Breo Ellipta. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules do not require the Part D plan to grant a tiering exception for a brand or biologic drug if the lower tiers on the formulary only contain generic alternative drugs. Breo Ellipta is a Tier 3 brand drug. The lower cost-sharing tiers only contain generic alternative drugs. Therefore, our decision is the Plan is not required to provide a tiering exception for Breo Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Proscar. 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 Proscar 5 mg. The drug is requested to treat androgenic alopecia. Drugs prescribed to promote hair growth (or treat hair loss) are excluded from coverage under Medicare Part D. Therefore the requested drug is excluded from coverageMedicare law excludes certain drugs from Part D coverage. Proscar is one of those excluded drugs because it is a drug used for cosmetic purposes or to promote hair growth. The record submitted by the Plan does not indicate that they provide supplemental coverage for Proscar. Therefore, the Plan is not required to cover Proscar. 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: Favorable

You asked the Plan to cover Nulojix 250 mg vial. The Plan did not grant this request. We received this case to conduct an independent review.Medicare law specifically excludes coverage for any drug under the Part D program for which payment would be available under Parts A or B of Medicare for that individual. Coverage is available under Medicare Part B for prescription drugs used in immunosuppressive therapy furnished to a beneficiary who has received an organ transplant, provided that Medicare Part A paid for the transplant in question. In this case, Nulojix will be administered in the enrollee's home. Therefore, it is not eligible for coverage under Medicare Part B and we sent the request to our physician reviewer to review for coverage under Medicare Part D.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Nulojix 250 mg vial. The drug is requested to treat kidney transplant. The prescriber has indicated why all alternatives required by the Plan would likely not be as effective as the requested drug for the enrollee, and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is medically necessary. Our Physician Reviewer's opinion is that formulary exception criteria are 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 met. Therefore, the Plan is required to cover Nulojix.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for Eliquis 5 mg purchased March 15, 2020 and Entresto 24-26 mg purchased March 17, 2020. The Plan did not grant this request. We received this case to conduct an independent review.EliquisIn this case, the records show that when Eliquis 5 mg was purchased on March 15, 2020, the claim straddled both the initial coverage stage and the coverage gap stage of the Part D benefit. An enrollee is responsible for the applicable copayment/coinsurance amount for each phase a claim straddles.Documentation provided by the Plan shows that the total cost for Eliquis 5 mg was $1438.46. The initial coverage phase requires a $141 copayment for this drug and day supply purchased. The Plan documentation also shows that there was $1,364.23 remaining in the initial coverage phase which is subtracted from the total cost of the drug. Of the amount subject to the initial coverage limit ($1,364.23) you only paid $141. This left a remaining total drug cost owed of $74.23.This remaining balance was subject to the coverage gap copayment/coinsurance amount of 25%. 25% of the remaining balance is $18.56. The total of the two figures owed during each benefit phase (initial coverage stage and coverage gap stage) is $159.56. The record shows that the enrollee was charged an amount that is less than or equal to the required copayment for each phase the claim was processed in. The cost of Eliquis 5 mg was purchased on March 15, 2020 was applied to your yearly true out-of-pocket (TrOOP) costs. Therefore, our decision is the Plan is not required to provide reimbursement for Eliquis 5 mg was purchased on March 15, 2020.EntrestoIn this case, the enrollee requested reimbursement for Entresto 24-26 mg purchased March 17, 2020. The record shows that the Plan provided coverage for Entresto 24-26 mg. When the claim for Entresto 24-26 mg was processed, the enrollee was in the coverage gap. While in the coverage gap, the enrollee is required to pay 25% of the price of brand name drugs (plus a portion of the dispensing fee) and 25% of the price of generic drugs. The amount the enrollee was charged was less than or equal to the required coverage gap copayment: the total cost of the claim was $1,664.32, you paid $416.09. The cost of Entresto 24-26 mg purchased March 17, 2020 was applied to the enrollee's yearly true out-of-pocket (TrOOP) costs. Therefore, our decision is the Plan is not required to provide reimbursement for Entresto 24-26 mg purchased March 17, 2020.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to provide a tiering exception for Trulance. 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 Trulance 3mg. Trulance 3mg is prescribed to treat chronic idiopathic constipation. Trulance 3mg is a brand drug on Tier 4 of the Plan's formulary. Tier 3 brand drugs to treat the enrollee's condition include: Linzess, a drug with the same mechanism of action as Trulance, and Amitiza, a drug with a different mechanism of action than Trulance. You have indicated that the enrollee has failed multiple drugs including the two noted lower tier drugs. The prescriber has indicated why all eligible 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.Our Physician Reviewer's opinion is that tiering exception criteria are met.Medicare rules permit a Plan to grant an exception to its tiering structure whenever it determines that the non-preferred or higher cost-sharing 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 met. Therefore, our decision is the Plan is required to provide a tiering exception for Trulance from the date of the Plan's initial denial.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Nucynta ER. 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 Nucynta ER. The drug is requested to treat chronic pain syndrome. 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 Nucynta ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Entresto. 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 Entresto 49/51mg. Entresto 49/51mg is requested to treat your condition. The requested 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 your condition. Therefore, the requested 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 Entresto.