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

You asked the Plan to cover and provide reimbursement for TDVAX Vaccine (Tetanus Diptheria Toxoids) received at your physician's office. The Plan did not grant this request. We received this case to conduct an independent review.The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. 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 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, you submitted a request for reimbursement to the Plan for TDVAX Vaccine (Tetanus Diptheria Toxoids) received at your physician's office. The case record includes proof of payment. The Plan denied reimbursement on the basis that the National Drug Code (NDC) 14362-0111-40 provided was invalid. You then requested a corrected NDC number from your physician's office. MAXIMUS verified using FDA sources that NDC 14362-0111-4 is a valid NDC eligible for coverage under Medicare Part D. TDVAX Vaccine (Tetanus Diptheria Toxoids) is on the Plan's formulary as a Tier 3 Vaccine. The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to provide applicable reimbursement for TDVAX Vaccine (Tetanus Diptheria Toxoids) received at your physician's office.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

You asked the Plan to cover Brovana Nebulizer Solution. The Plan did not grant this request. We received this case to conduct an independent review.Medicare law specifically excludes coverage for any drug for which payment would be available under Part A or Part B of Medicare for that individual. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. Medicare Part B local policy states that a small volume nebulizer and related compressor are covered when medically necessary to administer Brovana Nebulizer Solution for the management of obstructive pulmonary disease.In this case, the record shows that Brovana Nebulizer Solution is administered through a nebulizer in the home for a diagnosis of J45.909 Unspecified asthma, uncomplicated. There is no indication that it is not administered through a small volume nebulizer. It appears that this medication is eligible for coverage under Part B rather than Part D. Drugs which are eligible for coverage under Part B are excluded from Part D coverage by Medicare law. Therefore, it is our decision that the Part D Plan is not required to cover Brovana Nebulizer Solution. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.You may wish to submit this request to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Combigan 0.2%-0.5%. 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 of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) if the lower tier(s) on the formulary only contain(s) generic alternative drugs. Combigan 0.2%-0.5% is a Tier 3 brand drug. The lower cost-sharing tier(s) only contain(s) generic alternative drugs. Therefore, our decision is the Plan is not required to provide a tiering exception for Combigan 0.2%-0.5%.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Incruse 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 of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) if the lower tier(s) on the formulary only contain(s) generic alternative drugs. Incruse Ellipta is a Tier 3 brand drug. The lower cost-sharing tier(s) only contain(s) generic alternative drugs. Therefore, our decision is the Plan is not required to provide a tiering exception for Incruse Ellipta.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to provide reimbursement for Potassium Chloride 1.33 meq/mL. The Plan did not grant this request. We received this case to conduct an independent review.The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, you received Potassium Chloride 1.33 meq/mL while at the hospital. You requested reimbursement from the Part D Plan. Your request includes proof of payment for the Potassium Chloride. The Plan denied the request on the basis that you did not provide a valid National Drug Code (NDC) associated with Potassium Chloride 1.33 meq/mL. Although you provided NDC 00603-1542-30,which is not a Part D eligible NDC, Potassium Chloride 1.33 meq/mL is on the Plan's 2019 Formulary with no restrictions. Additionally, Medicare rules state that when a Plan sponsor could acquire missing information, such as the NDC number, by contacting the enrollee's pharmacist, physician, or other prescriber, it should do so instead of relying on the enrollee to provide the information. The Plan may utilize the remainder of the 30-day payment period after approval is granted to obtain missing information in order to determine the amount of reimbursement to be provided. Thus, the Plans reimbursement rules as stated in the Evidence of Coverage have been met, and the Plan should obtain missing NDC information in order to process reimbursement. Therefore, the Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to provide coverage and reimbursement for Potassium Chloride 1.33 meq/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: Unfavorable

You asked the Plan to provide a tiering exception for Lumigan. 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 of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) if the lower tier(s) on the formulary only contain(s) generic alternative drugs. Lumigan is a Tier 3 brand drug. The lower cost-sharing tier(s) only contain(s) generic alternative drugs. Therefore, our decision is the Plan is not required to provide a tiering exception for Lumigan.Restasis:We are dismissing the request for a tiering exception for Restasis. We received your letter asking for an appeal of the Plan's unfavorable determination for a tiering exception for Restasis. Medicare rules do not allow us to review this case until you have completed the appeal process with the Plan. You may request a Reconsideration appeal with us after the Plan issues an unfavorable Redetermination. You may wish to submit this request to the Plan at this time.
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 Oxycodone HCL 30 mg. The Plan did not grant this request. We received this case to conduct an independent review.In this case, you requested coverage and reimbursement for Oxycodone HCL 30 mg that was already covered by GoodRx. According to the GoodRx terms of use found on their website (https://www.goodrx.com/medicare): Medicare is supposed to make your prescription drugs affordable. But, as many seniors know, some drugs are still expensive, and some aren't covered at all. And, of course, there's the infamous donut hole.GoodRx makes it easy to compare your Medicare co-pays against GoodRx coupon prices to see which can save you more. Keep in mind that you cannot use GoodRx and Medicare at the same time. However, you can use GoodRx instead of government-funded programs, such as Medicare of Medicaid, to pay for your prescription medications. When you decided to use GoodRx you acknowledged and agreed that GoodRx will be treated as the primary pay or with respect to medications that you have selected to purchase through the GoodRx Services. Thus, Oxycodone HCL 30 mg purchased is 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 Oxycodone HCL 30 mg.
Appeal type: Prescription Drug
Decision: Unfavorable

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.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 needed additional information from the prescriber to determine whether the you are using Lidocaine 5% Ointment for an FDA-approved use, or a use listed in the Medicare-approved compendia. The requested information was not received. As a result, we could not confirm that the drug is being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit. An exceptions request based on medical necessity cannot be considered because it cannot be confirmed that the drug meets 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

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 Cetirizine HCL and Flonase. The Plan did not grant this request. We received this case to conduct an independent review.Medicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drugs' classification or determined from other available resources that the drugs are non-prescription or OTC drugs. Therefore, Cetirizine HCL and Flonase are not eligible for Part D coverage, and the Plan is not required to cover 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: 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 Tamsulosin HCL 0.4 mg. 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. The Part D Plan enrollee may pay part of the cost of a covered drug during the initial coverage period as a copayment or coinsurance. The amount of the copayment or coinsurance will vary depending on the drug's tier and place of purchase. Tamsulosin HCL 0.4 mg is on Tier 1 of the Plan's 2020 Formulary. The Plan verified the claim has not yet been paid, the pharmacy used is a standard in-network pharmacy and you were in the initial coverage limit at the time of purchase. The Plan has not provided any reason why the claim should not be paid at this time.The case record indicates that the Plan did not provide coverage in accordance with the Part D Plan contract. Therefore, our decision is the Plan is required to provide reimbursement for Tamsulosin HCL 0.4 mg.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

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 Temazepam 30 mg. 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. The Part D Plan enrollee may pay part of the cost of a covered drug during the initial coverage period as a copayment or coinsurance. The amount of the copayment or coinsurance will vary depending on the drug's tier and place of purchase. Temazepam 30 mg is on Tier 1 of the Plan's 2020 Formulary. The Plan verified the claim has not yet been paid, the pharmacy used is a standard in-network pharmacy and you were in the initial coverage limit at the time of purchase. The Plan has not provided any reason why the claim should not be paid at this time.The case record indicates that the Plan did not provide coverage in accordance with the Part D Plan contract. Therefore, our decision is the Plan is required to provide reimbursement for Temazepam 30 mg. 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

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 Lisinopril 10 mg. 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. The Part D Plan enrollee may pay part of the cost of a covered drug during the initial coverage period as a copayment or coinsurance. The amount of the copayment or coinsurance will vary depending on the drug's tier and place of purchase. Lisinopril 10 mg is on Tier 1 of the Plan's 2020 Formulary. The Plan verified the claim has not yet been paid, the pharmacy used is a standard in-network pharmacy and you were in the initial coverage limit at the time of purchase. The Plan has not provided any reason why the claim should not be paid at this time.The case record indicates that the Plan did not provide coverage in accordance with the Part D Plan contract. Therefore, our decision is the Plan is required to provide reimbursement for Lisinopril 10 mg.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 provide reimbursement for Methylphenidate 20 mg. The Plan did not grant this request. We received this case to conduct an independent review.In this case, you requested coverage and reimbursement for Methylphenidate 20 mg that was already covered by GoodRx. According to the GoodRx terms of use found on their website (https://www.goodrx.com/medicare): Medicare is supposed to make your prescription drugs affordable. But, as many seniors know, some drugs are still expensive, and some aren't covered at all. And, of course, there's the infamous donut hole.GoodRx makes it easy to compare your Medicare co-pays against GoodRx coupon prices to see which can save you more. Keep in mind that you cannot use GoodRx and Medicare at the same time. However, you can use GoodRx instead of government-funded programs, such as Medicare of Medicaid, to pay for your prescription medications. When you decided to use GoodRx you acknowledged and agreed that GoodRx will be treated as the primary pay or with respect to medications that you have selected to purchase through the GoodRx Services. Thus, Methylphenidate 20 mg is 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 Methylphenidate 20 mg.
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 One Touch Ultra test strips. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules state that the definition of a Part D drug includes medical supplies directly associated with the injection of insulin. Test strips, lancets and needle disposal systems are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Part D. You asked the Part D Plan to provide coverage for test strips. Diabetic test strips are a medical supply that is specifically excluded from Part D coverage by Medicare law. Therefore, our decision is the Part D Plan is not required to cover or provide reimbursement for One Touch Ultra test strips.This decision does not concern the medical necessity or appropriateness of the requested item. It only establishes if payment can be made under the Medicare Part D benefit.Please note: the Plan provided documentation that reimbursement has been approved under the enhanced portion of your benefit. You may wish to contact the Plan regarding how and when coverage and/or reimbursement for One Touch Ultra test strips purchased will be provided under the enhanced portion of your benefit. You may also wish to submit this request to the Medicare Part B carrier.
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 Senna-Lax, Sodium Citrate-Citric Acid and Tramadol 50 mg. The Plan did not grant this request. We received this case to conduct an independent review.Senna-Lax and Sodium Citrate-Citric AcidMedicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drugs' classification or determined from other available resources that the drugs are non-prescription or OTC drugs. Therefore, Senna-Lax and Sodium Citrate-Citric Acid received 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.TramadolMedicare Part D does not cover drugs that are not FDA approved for both safety and effectiveness. We determined that Tramadol (63739067110) is not FDA approved for both safety and effectiveness by checking FDA sources. The research shows Tramadol (63739067110) has a marketing end date. Therefore, the Plan is not required to cover or provide reimbursement for Tramadol.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.Scopolamine and EstradiolWe are dismissing the request for Scopolamine and Estradiol. The Part D Plan provided documentation that the request for coverage or payment for Scopolamine and Estradiol was approved as requested. Since the Plan has agreed to provide coverage or payment, there is no need for a reconsideration review.Contact the Part D Plan to learn more about how and when coverage or payment will be provided for Scopolamine and Estradiol.