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

At issue is Dimenhydrinate. 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 the enrollee received the drug while in an outpatient setting. 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 iproof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement indicating payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Diphenhydramine Hydrochloride. 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 the enrollee received the drug while in an outpatient setting. 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 iproof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement indicating payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Ephedrine Sulfate. 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 the enrollee received the drug while in an outpatient setting. 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 iproof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement indicating payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Fentanyl Citrate. 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 the enrollee received the drug while in an outpatient setting. 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 iproof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement indicating payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Glycopyrrolate. 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 the enrollee received the drug while in an outpatient setting. 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 iproof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement indicating payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Hydromorphone. 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 the enrollee received the drug while in an outpatient setting. 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 iproof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement indicating payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Isosulfan Blue. 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 the enrollee received the drug while in an outpatient setting. 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 iproof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement indicating payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Levothyroxine. 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 the enrollee received the drug while in an outpatient setting. 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 iproof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement indicating payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Methocarbamol. 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 the enrollee received the drug while in an outpatient setting. 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 iproof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement indicating payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Metoprolol Succinate. 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 the enrollee received the drug while in an outpatient setting. 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 iproof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement indicating payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Midazolam. 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 the enrollee received the drug while in an outpatient setting. 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 iproof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement indicating payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Neostigmine Methylsulfate. 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 the enrollee received the drug while in an outpatient setting. 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 iproof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement indicating payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Ondansetron Hydrochloride. 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 the enrollee received the drug while in an outpatient setting. 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 iproof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement indicating payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Oxycodone. 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 the enrollee received the drug while in an outpatient setting. 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 iproof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement indicating payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Phenylephrine. 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 the enrollee received the drug while in an outpatient setting. 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 iproof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement indicating payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Propofol. 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 the enrollee received the drug while in an outpatient setting. 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 iproof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement indicating payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Rocuronium. 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 the enrollee received the drug while in an outpatient setting. 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 iproof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement indicating payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tramadol Hydrochloride. 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 the enrollee received the drug while in an outpatient setting. 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 iproof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement indicating payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Acetaminophen 500 milligram tablet to treat unknown. 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. Acetaminophen 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 reimbursement for Fluzone high dose prefilled syringe injection. The Part D plan auto forwarded the case to us for review.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 received Fluzone injection on August 24, 2023. 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 by the enrollee, and a physician's statement including the prescriber's National Provider Identifier (NPI) number and National Drug Code (NDC) of the requested vaccine was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Rybelsus 7 milligram tablet 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.The submitted documentation shows the enrollee requested the Part D plan to provide reimbursement for the requested drug purchased from a network pharmacy and processed through another insurance provider, Cigna, in error. Your claim was processed as a coordination of benefits (COB) claim and Cigna made partial payment. However, the plan indicates that it cannot process a COB claim against your Med D benefit when it is designated as primary coverage. An explanation of benefits (EOB) statement showing the amount paid by the primary insurance on this claim is required to process a COB claim. As such, we determined that the plan is not required to provide reimbursement.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 Loratadine 10 milligram tablet 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.Loratadine 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 Ozempic 0.25 or 0.5 milligram per dose pen injector to treat obesity. 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 Prolia 60 milligram per milliiter subcutaneous solution to treat postmenopausal osteoporosis. 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 plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.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 and reimbursement for Testosterone 7.500 gram micronized powder prescribed as an ingredient for a compounded drug to treat the enrollees condition. 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 documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The plan provided documentation showing the request is for a compounded drug. The compounded drug also included Ethoxy Diglycol and base, PCcA (Professional Compounding Centers of America) Vanpen. The requested product is not an approved drug by the United States Food and Drug Administration (USFDA). Products not approved as drugs by the USFDA are excluded from coverage under the Medicare Part D drug benefit. Therefore, reimbursement cannot be allowed.This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Nuedexta 20 milligram/10 milligram oral capsule to treat pseudobulbar affect. 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.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that the enrollee has satisfied the plans prior authorization coverage criteria. We received additional documentation and included it in the review.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.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 Dexcom G6 Sensor. 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. Medicare classifies continuous glucose monitoring systems as durable medical equipment. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment. Additionally, payment will be made under Medicare Part B for the supplies necessary for the effective use of durable medical equipment, including supplies for a continuous glucose monitoring system. Any drug/item available for coverage under Medicare Part B cannot be covered under Part D, per Medicare rules. Therefore, the requested item is not eligible for Medicare Part D coverage.This decision does not address the medical necessity of the item. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit the request for coverage through Medicare Part B.