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

At issue is reimbursement for Colchicine 0.6 milligram tablet prescribed for unknown 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 enrollee received the requested drug from an out-of-network pharmacy. 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 showing the amount that was paid for the drug was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Tenivac 2 limit of flocculation (lf) per 0.5 milliliter/5 lf per 0.5 milliliter intramuscular suspension for preparation for travel outside the country. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The submitted documentation supports the vaccine was administered as prophylaxis which is a medically accepted indication and covered under Part D. The enrollee provided a statement indicating full payment was made for the vaccine. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Remedy Phytoplex antifungal 2 percent ointment to treat the enrollees condition. The Part D plan denied the request for coverage and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Remedy Phytoplex antifungal 2 percent ointment is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare Part D coverage. As such, the plan is not required to reimburse you for the cost of Remedy Phytoplex antifungal 2 percent ointment. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Triad 71 gram wound dressing paste. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The plan provided claim information for the enrollee indicating the drug at issue was dispensed at a pharmacy not in the plans network on the date the prescription was filled. In these instances, the enrollee may be responsible for paying the difference between what he/she pays for the drug at the out of network pharmacy and the cost that the plan would cover at an in network pharmacy. The documentation does not support an extreme emergency that would require the drug be immediately supplied and the drug could have been received from a network pharmacy. Therefore, we determined that the plan is not required to provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Torsemide 20 milligram tablet prescribed for an unknown diagnosis. The Part D plan auto forward the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee received the requested drug at an out-of-network pharmacy. 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 showing the amount that was paid for the drug was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oseltamivir 75 milligram capsule prescribed for influenza diagnosis. 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 purchased drugs from a pharmacy outside of the United States. Drugs purchased outside of the United States are excluded from coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Fluconazole 150 milligram tablet. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The submitted documentation shows the enrollee purchased Fluconazole from an outpatient pharmacy. According to the plan's Evidence of Coverage, if the 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. The enrollee provided a pharmacy receipt including the amount charged and proof of payment for the requested drug. Therefore, the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Nitrofurantoin Monohyd Macro 100 milligram capsule. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The submitted documentation shows the enrollee purchased Nitrofurantoin Monohyd Macro from an outpatient pharmacy. According to the plan's Evidence of Coverage, if the 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. The enrollee provided a pharmacy receipt including the amount charged and proof of payment for the requested drug. Therefore, the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zonisamide 100 milligram capsule. The Part D plan denied 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 a discount card was applied to the purchase of the requested drug. Discount cards are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When the enrollees benefit card was used, the enrollee acknowledged and agreed that the discount program will be treated as the primary payor with respect to the medications that are purchased through the discount program. Therefore, the plan is not required to cover or provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Finasteride 5 milligram tablet prescribed for an unspecified diagnosis, date of service from 6/6/2023. 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 purchased the requested drug from a retail pharmacy. The plans 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. The submitted documentation includes a receipt for the requested drug and reimbursement request form. The National Drug Code is a valid code for the requested drug. In addition, information regarding the prescriber and prescription details were submitted. Therefore, we determined the plan is required to provide reimbursement for the requested drug based on the enrollee's cost share stage, as the reimbursement criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Promethazine 6.25 milligram per 5 milliliter oral syrup to treat cough. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. Drugs prescribed for the symptomatic relief of coughs are excluded from the Part D coverage. Therefore, the requested drug is excluded from Medicare Part D coverage. Please note, this reconsideration decision was based on the plans 2023 coverage criteria.This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alendronate Sodium 70 milligram tablet. 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 reviewed all available documentation. According to the plans 2023 Evidence of Coverage, reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan approved for the drug. We determined this drug was paid correctly and no further reimbursement is required by the plan. Please note, this reconsideration decision was based on the plans 2023 coverage criteria.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amoxicillin/Clavulanate Potassium 500/125 milligram tablet. 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 reviewed all available documentation. According to the plans 2023 Evidence of Coverage, reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan approved for the drug. We determined this drug was paid correctly and no further reimbursement is required by the plan. Please note, this reconsideration decision was based on the plans 2023 coverage criteria.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Glyburide/Metformin 5/500 milligram tablet. 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 reviewed all available documentation. According to the plans 2023 Evidence of Coverage, reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan approved for the drug. We determined this drug was paid correctly and no further reimbursement is required by the plan. Please note, this reconsideration decision was based on the plans 2023 coverage criteria.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lantus Solostar 100 units per milliliter subcutaneous solution. 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 reviewed all available documentation. According to the plans 2023 Evidence of Coverage, reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan approved for the drug. 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 Lantus Solostar 100 units per milliliter subcutaneous solution. 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 reviewed all available documentation. According to the plans 2023 Evidence of Coverage, reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan approved for the drug. We determined this drug was paid correctly and no further reimbursement is required by the plan. Please note, this reconsideration decision was based on the plans 2023 coverage criteria.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pravastatin Sodium 10 milligram tablet. 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 reviewed all available documentation. According to the plans 2023 Evidence of Coverage, reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan approved for the drug. We determined this drug was paid correctly and no further reimbursement is required by the plan. Please note, this reconsideration decision was based on the plans 2023 coverage criteria.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Verapamil ER (extended release) 180 milligram tablet. 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 reviewed all available documentation. According to the plans 2023 Evidence of Coverage, reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan approved for the drug. We determined this drug was paid correctly and no further reimbursement is required by the plan. Please note, this reconsideration decision was based on the plans 2023 coverage criteria.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Vitamin D3 5000 international units oral capsule. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. Vitamin d3 is a prescription vitamin. Prescription vitamin and mineral products are excluded from coverage under Medicare Part D. This is regardless of whether the vitamin or mineral product is being prescribed to correct a deficiency or to treat a disease process. Therefore, the requested drug is excluded from Medicare Part D coverage. Please note, this reconsideration decision was based on the plans 2023 coverage criteria.This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Aspirin 81 milligram tablet. The Part D plan denied the request for coverage and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Aspirin 81 milligram tablet is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Bisacodyl 10 milligram suppository. The Part D plan denied the request for coverage and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Bisacodyl 10 milligram suppository is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Potassium Chloride micronized 20 milliequivalent tablet. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. Potassium Chloride micronized is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Senna/Docusate Sodium 8.6/50 milligram tablet. The Part D plan denied the request for coverage and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Senna/Docusate Sodium 8.6/50 milligram tablet is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Sodium Phosphate 19/7 gram per 118 milliliter enema. The Part D plan denied the request for coverage and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Sodium Phosphate 19/7 gram per 118 milliliter enema is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prednisone 20 milligram tablet prescribed for an unknown diagnosis. 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 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.The documentation submitted does not include a diagnosis or reason the drug was required. The information also does not include a receipt for the purchase of the drug. 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 showing the amount that was paid for the drug was not provided. Therefore, we determined that the plan is not required to provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Upneeq 0.1 percent solution. 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.For the drug at issue to be covered under Medicare Part D, the manufacturer of the drug must participate in the Medicare Coverage Gap Discount Program. The manufacturer of this drug is not participating in the program. Therefore, the requested drug is excluded from Medicare Part D coverage.This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Physicians Elemental Diet (Dextrose free) to treat the enrollees condition. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Physicians Elemental Diet (Dextrose free) is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare Part D coverage.This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Lidocaine 5 percent ointment to treat back pain. 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. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition 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 condition. Therefore, the drug is being prescribed for a non-medically accepted indication.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 coverage for Xeljanz XR 11 milligram tablet to treat sarcoidosis. 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. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition 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 condition. Therefore, the drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.