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

At issue is Cephalexin 500 milligram tablet to treat a urinary tract infection. 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 purchased drugs from a pharmacy on a cruise ship. Drugs purchased on a cruise ship are considered foreign claims outside of the United States and are excluded from coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Phenazopyridine Hydrochloride 95 milligram tablet for urinary tract infection symptoms. 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 purchased drugs from a pharmacy on a cruise ship. Drugs purchased on a cruise ship are considered foreign claims outside of the United States and are excluded from coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bromfanac Sodium powder prescribed as part of a compound drug. 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.Drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The submitted documentation indicates the requested drug is a bulk powder. Therefore, the compounded drug is excluded from coverage under Part D. 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 Moxifloxacin powder prescribed as part of a compound drug. 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.Drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The submitted documentation indicates the requested drug is a bulk powder. Therefore, the compounded drug is excluded from coverage under Part D. 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 Prednisolone Sodium Phosphate powder prescribed as part of a compound drug. 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.Drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The submitted documentation indicates the requested drug is a bulk powder. Therefore, the compounded drug is excluded from coverage under Part D. 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: Favorable

At issue is Shingrix 0.5 milliliter injection prescribed for the enrollee's 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.The submitted documentation shows the enrollee received the vaccine at the prescriber's office. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or prescribers office. 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 enrollee provided a statement from the prescribers office full payment was made for the vaccine and administration fee. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tetanus/Diphtheria/Pertussis vaccine and administration fee for date of 3/31/23. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee received a Tetanus/Diphtheria/Pertussis vaccine. The plans Evidence of Coverage states, if the enrollee pays the full cost of a vaccine and administration fee, 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 and administration was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cephalexin 250 milligram capsule for date July 10, 2022, prescribed for unknown diagnosis. 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 of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for Cephalexin 250 milligram capsule was approved and copayment was charged correctly to the enrollee at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cephalexin 500 milligram capsule for dates October 31, 2022, and November 8, 2022, prescribed for unknown diagnosis. 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 of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for Cephalexin 500 milligram capsule was approved and copayment was charged correctly to the enrollee at the point of sale for both dates above. The plans Evidence of Coverage indicates 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 normally pays for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cerave Daily Moisturizing Lotion prescribed for unknown diagnosis. 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Cerave Daily Moisturizing Lotion is an over-the-counter drug and not eligible for coverage under Part D. Therefore, we determined the plan is not required to provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clopidogrel 75 milligram tablet for dates July 12, 2022, August 9, 2022, September 3, 2022, October 10, 2022, and November 7, 2022, prescribed for unknown diagnosis. The Part D plan denied the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for Clopidogrel 75 milligram tablet were approved and copayment was charged correctly to the enrollee at the point of sale for all dates above. The plans Evidence of Coverage indicates 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 normally pays for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Doxycycline Hyclate 100 milligram tablet for the date September 25, 2022, prescribed for unknown diagnosis. 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 of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for Doxycycline Hyclate 100 milligram tablet was approved and copayment was charged correctly to the enrollee at the point of sale for the date above. The plans Evidence of Coverage indicates 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 normally pays for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Doxycycline Monohydrate 100 milligram capsule for the date November 20, 2022, prescribed for unknown diagnosis. 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 of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for Doxycycline Monohydrate 100 milligram capsule was approved and copayment was charged correctly to the enrollee at the point of sale for the date above. The plans Evidence of Coverage indicates 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 normally pays for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Escitalopram 10 milligram tablet for the date November 22, 2022, prescribed for unknown diagnosis. 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 of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for Escitalopram 10 milligram tablet was approved and copayment was charged correctly to the enrollee at the point of sale for the date above. The plans Evidence of Coverage indicates 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 normally pays for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Escitalopram 5 milligram tablet for the dates July 5, 2022, August 1, 2022, August 31, 2022, and October 1, 2022, prescribed for unknown diagnosis. 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 of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for Escitalopram 5 milligram tablet was approved and copayment was charged correctly to the enrollee at the point of sale for all dates above. The plans Evidence of Coverage indicates 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 normally pays for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Furosemide 20 milligram tablet for the dates August 30, 2022 and September 21, 2022, prescribed for unknown diagnosis. 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 of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for Furosemide 20 milligram tablet was approved and copayment was charged correctly to the enrollee at the point of sale for all dates above. The plans Evidence of Coverage indicates 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 normally pays for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Furosemide 40 milligram tablet for the dates September 26, 2022 and November 30, 2022, prescribed for unknown diagnosis. 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 of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for Furosemide 40 milligram tablet was approved and copayment was charged correctly to the enrollee at the point of sale for all dates above. The plans Evidence of Coverage indicates 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 normally pays for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gabapentin 100 milligram capsule for the dates July 29, 2022, August 26, 2022, September 24, 2022, October 10, 2022, November 8, 2022, and November 19, 2022, prescribed for unknown diagnosis. 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 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 claim for fill date September 24, 2022, was rejected at point of sale for refill too soon, and the amount charged to the enrollee was an out-of-pocket expense. We determined this drug was paid correctly and no further reimbursement is required by the plan. The plan also submitted documentation that shows the claims for Gabapentin 100 milligram capsule was approved and copayment was charged correctly to the enrollee at the point of sale for all the remaining dates above. The plans Evidence of Coverage indicates 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 normally pays for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxyurea 500 milligram capsule for the dates July 15, 2022, August 23, 2022, September 20, 2022, October 29, 2022, and November 25, 2022, prescribed for unknown diagnosis. 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 of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for Hydroxyurea 500 milligram capsule was approved and copayment was charged correctly to the enrollee at the point of sale for all the dates above. The plans Evidence of Coverage indicates 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 normally pays for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Iodosorb Gel prescribed for unknown diagnosis. 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Iodosorb Gel is not a Medicare Part D eligible drug. This item is not listed in the Food and Drug Administration website as a drug. Therefore, we determined the plan is not required to provide reimbursement for the requested item.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 4 percent patch prescribed for unknown diagnosis for dates July 2, 8, 13, 16, 20, 25, and 29 of year 2022. Also, dates August 3, 8, 16, 21, 26, and 31 of year 2022 and Sept 4, 9, 16, 20, 24, and 29 of year 2022. And the dates of October 3, 8, of 2022 and November 2, 8, 13, 18, 24, and 30 of year 2022. 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Lidocaine 4 percent patch is an over-the-counter drug and not eligible for coverage under Part D. Therefore, we determined the plan is not required to provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent ointment prescribed for unknown diagnosis for the dates October 3, 2022 and November 14, 2022. 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 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. Medicare rules state that for prescription drugs to be covered under Part D when the enrollee has elected hospice, the drug must not be related to the hospice diagnosis. There is indication the enrollee is under hospice care. The submitted documentation is not sufficient to show the drug is not being used for a hospice diagnosis. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lisinopril 5 milligram tablet for the dates August 1, 2022, August 31, 2022, September 30, 2022, and November 23, 2022, prescribed for unknown diagnosis. 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 of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for Lisinopril 5 milligram tablet was approved and copayment was charged correctly to the enrollee at the point of sale for all the dates above. The plans Evidence of Coverage indicates 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 normally pays for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is MediHoney 100 percent paste prescribed for unknown diagnosis. 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.MediHoney 100 percent paste is an over-the-counter drug and not eligible for coverage under Part D. Therefore, we determined the plan is not required to provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Melatonin 3 milligram tablet for dates July 12, 2022, August 10, 2022, September 5, 2022, October 2, 2022, October 31, 2022, and November 27, 2022, prescribed for unknown diagnosis. 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Melatonin is an over-the-counter drug and not eligible for coverage under Part D. Therefore, we determined the plan is not required to provide reimbursement for the requested drug.