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

You asked the Plan to cover Hydrocodone/Acetaminophen. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Hydrocodone/Acetaminophen 10/325 mg, #120. Hydrocodone/Acetaminophen 10/325 mg is requested for ongoing treatment of chronic non-malignant pain. The Plan's redetermination (appeal) denial letter of May 8, 2020 states that coverage of the requested drug was denied for safety reasons - specifically, there was no prescriber statement addressing the medical necessity for the use of the requested drug, Hydrocodone/Acetaminophen 10/325 mg, in combination with Alprazolam. The enrollee does not satisfy the Plan's coverage criteria. You submitted a request for reconsideration on May 11, 2020; however you did not address the Plan's safety concerns stated in their appeal denial letter. You have not sufficiently addressed the Plan's coverage criteria and/or have not indicated why all alternatives required by the Plan would likely not be as effective for the enrollee as the requested drug, and/or would likely cause adverse reaction(s) or other harm to the enrollee. Our Physician's opinion is that neither prior authorization nor prior authorization exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. A Plan must grant an exception to prior approval rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on the available documentation, our Physician Reviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is not required to cover Hydrocodone/Acetaminophen.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Vraylar. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Vraylar. The drug is requested to treat bipolar disorder, unspecified and post-traumatic stress disorder, which are off-label (non-FDA approved) uses. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted conditions. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted conditions.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Vraylar for the diagnosed conditions. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for these conditions. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Vraylar. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Oxycontin ER. The Plan did not grant this request. We received this case toconduct an independent review.We asked a Physician Reviewer to determine whether the Plan was correct in denying the request forOxycontin ER, which is not on the Plan's formulary. Our Physician Reviewer needed additionalinformation from the prescriber to make this determination. The prescriber was asked to address whetherthe drugs offered by the Plan would: (1) not be as effective as the requested non-formulary drug; and/or (2)have adverse effects. The requested information was not received. Based on a review of the availabledocumentation, our Physician Reviewer's opinion is that formulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requesteddrug is medically necessary, consistent with the prescriber's statement. Based on a review of the availabledocumentation, our Physician Reviewer's opinion is that formulary exception criteria are not met.Therefore, the Plan is not required to cover Oxycontin ER.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Tetrabenzaine. The Plan did not grant this request. We received this case toconduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Tetrabenzaine.Tetrabenzaine is requested for ongoing treatment of dystonic tics. The enrollee does not satisfy the Plan'scoverage criteria. You have indicated why all alternatives required by the Plan (Austedo) would likely notbe as effective as the requested drug for the enrollee, and/or would likely cause adverse reaction(s) or otherharm to the enrollee. Therefore, an exception to the Plan's coverage criteria is medically necessary. OurPhysician Reviewer's opinion is that prior authorization exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. APlan must grant an exception to prior approval rules if it determines that the requested drug is medicallynecessary, consistent with the prescriber's statement. Based on the available documentation, our PhysicianReviewer's opinion is that an exception to prior approval criteria is met. Therefore, our decision is the Planis required to cover Tetrabenzaine.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Flector (Diclofenac Epolamine) 1.3% patch. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Flector 1.3% patch.Flector 1.3% patch is requested for treatment of chronic knee/back pain which resulted from a motor vehicle accident a few months ago, which is an off-label (non-FDA approved) use. The prescriber has indicated that the enrollee is unable to tolerate oral non-steroidal anti-inflammatory drugs due to gastroesophageal reflux; however, the Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Flector 1.3% patch for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Flector 1.3% patch. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Vitamin D 50,000 units. The Plan did not grant this request. We received thiscase to conduct an independent review.Medicare law excludes certain drugs from Part D coverage. Vitamin D is one of those excluded drugsbecause it is a prescription vitamin and mineral product. The record submitted by the Plan does not indicatethat they provide supplemental coverage for Vitamin D. Therefore, the Plan is not required to coverVitamin D.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for Silodosin 8 mg, Refresh Tears 0.5%, Senexon-S 8.6-50mg, Peg 3350, Melatonin 3 mg, Gabapentin 100 mg, Tramadol HCL 50 mg, Oxycodone HCL 5 mg,Hydrocodone-Acetaminophen 5-325 received September 19, 2019 through September 21, 2019. The Plandid not grant this request. We received this case to conduct an independent review.The Part D Plan covers prescriptions filled at an out-of-network pharmacy only in certain limitedcircumstances. In this case, you were at the hospital in September 2019. During this stay you receivedseveral self-administered drugs. You requested reimbursement from the Part D Plan. The Plan did notprocess the request. A representative from MAXIMUS Federal verified with the billing department of thehospital that the full balance for the self-administered drug portion of the bill has not yet been paid.Although you are currently making monthly payments, the full balance has not yet been paid. The Plan'sout-of-network coverage rules were not followed. Therefore, our decision is the Plan is not required toprovide reimbursement for Silodosin 8 mg, Refresh Tears 0.5%, Senexon-S 8.6-50 mg, Peg 3350,Melatonin 3 mg, Gabapentin 100 mg, Tramadol HCL 50 mg, Oxycodone HCL 5 mg, Hydrocodone-Acetaminophen 5-325 received September 19, 2019 through September 21, 2019 at this time.
Appeal type: Prescription Drug
Decision: Partially 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 cover and provide a tiering exception for Benlysa 200 mg/mL. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for coverage of Benlysa 200 mg/ mL. The drug is requested for ongoing treatment of active systemic lupus erythematosus (SLE). Additional medical information was requested by the Part D QIC. The prescribing physician was asked to address the prior authorization coverage criteria. The prescriber statement was returned. The enrollee satisfies the Plan's coverage criteria. Our Physician Reviewer's opinion is that prior authorization criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. Based on the available documentation, our Physician Reviewer's opinion is that prior approval criteria are met. Therefore, our decision is the Plan is required to cover Benlysa 200 mg/mL.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Celecoxib. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for a tiering exception for Celecoxib 100 mg capsule. The drug is requested to treat osteoarthritis pain. The drug is on tier three of the Plan's formulary. There are no available (equivalent) lower tier drugs on the Plan's formulary to treat the enrollee's condition. Therefore, the drug is not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of the same type in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug is being used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met because there are no lower cost-sharing tiered drugs of the same type for treating the enrollee's condition. Therefore, our decision is the Plan is not required to provide a tiering exception for Celecoxib.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Estradiol. The Plan did not grant this request. We received this case to conductan independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Estradiol 0.025 mg/24 hr patch. The drug is requested to treat osteopenia and hot flashes. The enrolleedoes not satisfy the Plan's coverage criteria. The prescriber has not sufficiently addressed the Plan'scoverage criteria and/or has not indicated why all alternatives required by the Plan would likely not be aseffective for the enrollee as the requested drug, and/or would likely cause adverse reaction(s) or other harmto the enrollee. Our Physician's opinion is that neither prior authorization nor prior authorization exceptioncriteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. APlan must grant an exception to prior approval rules if it determines that the requested drug is medicallynecessary, consistent with the prescriber's statement. Based on the available documentation, our PhysicianReviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is notrequired to cover Estradiol.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for the Testosterone Compound purchased March 13, 2020. The Plan did not grant this request. We received this case to conduct an independent review.Medicare Part D does not cover drugs that are not FDA approved. A representative of the pharmacy stated that bulk powder was used or would be used when compounding the prescription for the Testosterone Compound purchased March 13, 2020. Bulk powders used in pharmacy compounding are not reviewed and approved for safety and efficacy by the FDA. Therefore, the Plan is not required to cover or provide reimbursement for the Testosterone Compound purchased March 13, 2020. 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

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 Tretinoin 0.01% gel. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Tretinoin 0.01% gel. The drug is requested to treat acute skin change due to ultraviolet radiation, unspecified and acne keloid. Drugs prescribed for cosmetic purposes are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.Medicare law excludes certain drugs from Part D coverage. Tretinoin 0.01% gel is one of those excluded drugs because it is a drug used for cosmetic purposes or to promote hair growth. The record submitted by the Plan does not indicate that they provide supplemental coverage for Tretinoin 0.01% gel. Therefore, the Plan is not required to cover Tretinoin 0.01% gel. 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: Unfavorable

You asked the Plan to provide additional reimbursement for Ondansetron purchased at the pharmacy onMarch 20, 2020. The Plan did not grant this request. We received this case to conduct an independentreview.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 usas required by Medicare rules because it did not make a timely decision.Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. If you pay thefull cost of a prescription drug out-of-pocket or if you find you have paid more than you expected to payunder the Plan's coverage rules, you can ask the Plan to pay you back. When submitting a request forreimbursement, the Plan requires that you submit your receipt documenting the payment you have madealong with your reimbursement request.In this case, you submitted a request for reimbursement to the Plan for Ondansetron purchased March 20,2020 from your pharmacy and indicated on the date of purchase the insurance company had deniedcoverage due to prior authorization criteria was not met. It appears the Plan provided reimbursement forthis fill once they completed and approved your request for prior authorization, however reimbursementwas provided based the Plan's negotiated contract rate.For cash purchases made at in-network pharmacies, the enrollee is responsible for the difference betweenthe cash price and the Plan's negotiated price, except for circumstances in which a pharmacy's or payer'ssystem is offline at the time of purchase, or in which there is evidence of an enrollment-related error orother a sponsor error that limited the enrollee's access to the negotiated price.Since the claim was rejected due to a prior authorization issue at the time of the purchase it appears that thisis a situation in which the Plan's policy of charging the enrollee the difference between the cash price paidand the Plan's contracted negotiated rate for the drug is applicable. Therefore, it is our decision that thePlan is not required to provide additional reimbursement for Ondansetron purchased March 20, 2020 fromyour pharmacy.Since the claim was rejected due to a prior authorization request issue at the time of the purchase it appearsthat this is a situation in which the Plan's policy of charging the enrollee the difference between the cashprice paid and the Plan's contracted negotiated rate for the drug is applicable. Therefore, it is our decisionthat the Plan is not required to provide additional reimbursement for Ondansetron purchased March 20,2020 from your pharmacy.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Jublia. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for a tiering exception for Jublia. Jublia is requested to treat the enrollee's condition. The requested drug is a brand drug on Tier 4 of the Plan's formulary. There are no similar lower tier brand drugs on the Plan's formulary to treat the enrollee's condition. Therefore, the requested drug is not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug is being used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met because there are no lower cost-sharing tiered drugs of the same type for treating the enrollee's condition. Therefore, our decision is the Plan is not required to provide a tiering exception for Jublia.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Repatha Sureclick. The Plan did not grant this request. We received this caseto conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Repatha Sureclick 140mg/mL. Repatha Sureclick 140mg/mL is requested for treatment ofhyperlipidemia in this enrollee with well documented atherosclerotic cardiovascular disease who has failedhigh dose Atorvastatin, 80 mg daily, with persistent elevation of LDL (low density lipoprotein) of 104.With the addition of Repatha to Atorvastatin, the enrollee's LDL decreased to 21. The enrollee satisfies thePlan's coverage criteria. Our Physician Reviewer's opinion is that prior authorization criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs.Based on the available documentation, our Physician Reviewer's opinion is that prior approval criteria aremet. Therefore, our decision is the Plan is required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Lidocaine 5% patch. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Lidocaine 5% patch. The drug is requested to treat pain in an enrollee with cervical spondylosis and lumbar radiculopathy, which is an off-label (non-FDA approved) use. Medical records from date of service April 13, 2020 were provided which support this diagnosis. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Lidocaine 5% patch for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Lidocaine 5% patch. 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.