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

At issue is Lidocaine 5 percent patch to treat lumbar spondylopathy. 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, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support a covered diagnosis and that the enrollee has satisfied the plans prior authorization coverage criteria. We received additional documentation and included it in the review.The submitted documentation includes a prescriber statement but does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. The use of the requested drug to treat the provided diagnosis 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 diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.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 Skyrizi 150 milligram per milliliter injection solution to treat psoriasis vulgaris. 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 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.The submitted documentation shows the enrollee is covered under a Pharmaceutical Assistance Program (PAP). Medicare rules state that PAPs operate outside of Medicare Part D. Therefore, we determined the drug is not eligible for coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eszopiclone 3 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan submitted documentation that shows the enrollee was still in the deductible stage for date of fill February 28, 2022. The enrollee was in the deductible stage for date of fill May 27, 2022 for part of the cost for this drug and entered the initial stage for the remaining amount when the requested drug was purchased. According to the plans 2022 formulary, Eszopiclone is a tier 4 drug. The plans Evidence of Coverage shows the enrollee has a deductible of $480 and standard copay in the initial coverage stage of 50 percent for tier 4 drugs. The enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. The plan approved cost of $296.43 for the date of fill February 28, 2022 was applied to the deductible. The plan approved cost for the drug for the date of fill May 27, 2022 was $236.61. After the applied deductible of $183.57, the remaining $53.04 was applied as copay. We determined that no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Metformin 500 milligram (mg) tablet. The Part D plan denied the request.We received the submitted documentation to perform an independent and de novo review.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a 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 reimbursement for Paroxetine 10 milligram (mg) tablet. The Part D plan denied the request.We received the submitted documentation to perform an independent and de novo review.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a 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 Dorzolamide Hydrochloride 2 percent ophthalmic solution prescribed for an unspecified diagnosis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The enrollee is requesting reimbursement for Dorzolamide Hydrochloride given as self-administered while in the hospital. The submitted documentation includes a hospital statement indicating the enrollee paid for the drug out of pocket. However, we researched Medicare resources and found that the requested drug is a repackaged drug with a National Drug Code (NDC) that is not listed with the Food and Drug Administration (FDA). Therefore, we determined that the plan is not required to cover or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Famotidine 20 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The enrollee is requesting reimbursement for Famotidine given as self-administered while in the hospital. The submitted documentation includes a hospital statement indicating the enrollee paid for the drug out of pocket. However, we researched Medicare resources and found that the requested drug is a repackaged drug with a National Drug Code (NDC) that is not listed with the Food and Drug Administration (FDA). Therefore, we determined that the plan is not required to cover or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Finasteride 5 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The enrollee is requesting reimbursement for Finasteride given as self-administered while in the hospital. The submitted documentation includes a hospital statement indicating the enrollee paid for the drug out of pocket. However, we researched Medicare resources and found that the requested drug is a repackaged drug with a National Drug Code (NDC) that is not listed with the Food and Drug Administration (FDA). Therefore, we determined that the plan is not required to cover or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latanoprost 0.005 percent ophthalmic solution prescribed for an unspecified diagnosis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The enrollee is requesting reimbursement for Latanoprost given as self-administered while in the hospital. The submitted documentation includes a hospital statement indicating the enrollee paid for the drug out of pocket. However, we researched Medicare resources and found that the requested drug is a repackaged drug with a National Drug Code (NDC) that is not listed with the Food and Drug Administration (FDA). Therefore, we determined that the plan is not required to cover or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Losartan Potassium 25 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The enrollee is requesting reimbursement for Losartan Potassium given as self-administered while in the hospital. The submitted documentation includes a hospital statement indicating the enrollee paid for the drug out of pocket. However, we researched Medicare resources and found that the requested drug is a repackaged drug with a National Drug Code (NDC) that is not listed with the Food and Drug Administration (FDA). Therefore, we determined that the plan is not required to cover or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Phenazopyridine Hydrochloride 100 milligram tablet treat an unspecified diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs that are not approved by the Food and Drug Administration (FDA) are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tamsulosin Hydrochloride 0.4 milligram capsule prescribed for an unspecified diagnosis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The enrollee is requesting reimbursement for Tamsulosin Hydrochloride given as self-administered while in the hospital. The submitted documentation includes a hospital statement indicating the enrollee paid for the drug out of pocket. However, we researched Medicare resources and found that the requested drug is a repackaged drug with a National Drug Code (NDC) that is not listed with the Food and Drug Administration (FDA). Therefore, we determined that the plan is not required to cover or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Menactra 0.5 milliliter injection prescribed for vaccination. 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 was administered the requested drug for vaccination in the prescriber's office. 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 or physician's statement showing the amount that was paid by the enrollee was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Hydromorphone Hydrochloride 4 milligram tablet prescribed to treat an unspecified diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plans 2022 Evidence of Coverage states, reimbursement for drugs is based the total cost of covered drugs, minus the required deductible, copay, or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The claim information shows the cost of the drug was more than the plan approved amount. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acetaminophen 325 milligram tablet.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amlodipine 5 milligram tablet prescribed to treat an unspecified diagnosis. The Part D plan auto-forwarded 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 purchased the requested drug from an out of network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aspirin 81 milligram tablet.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Atorvastatin 10 milligram tablet prescribed to treat an unspecified diagnosis. The Part D plan auto-forwarded 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 purchased the requested drug from an out of network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Atorvastatin 10 milligram tablet prescribed to treat an unspecified diagnosis. The Part D plan auto-forwarded 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 Atorvastatin as a self-administered drug in the hospital on date of service May 29, 2021. According to the plan's Evidence of Coverage, if the enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The enrollee provided a hospital statement including the amount charged for the self-administered drug. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clonidine 0.1 milligram tablet prescribed to treat an unspecified diagnosis. The Part D plan auto-forwarded 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 purchased the requested drug from an out of network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clopidogrel 75 milligram tablet prescribed to treat an unspecified diagnosis. The Part D plan auto-forwarded 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 purchased the requested drug from an out of network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levothyroxine 100 microgram prescribed to treat an unspecified diagnosis. The Part D plan auto-forwarded 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 purchased the requested drug from an out of network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lisinopril 10 milligram tablet prescribed to treat an unspecified diagnosis. The Part D plan auto-forwarded 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 purchased the requested drug from an out of network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lyrica 300 milligram capsule to treat fibromyalgia. 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, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed or were contraindicated. We received additional documentation and included it in the review. A prescriber statement was submitted but there were no medical records provided.The requested drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.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 Divigel 0.5 milligram gel packet prescribed for an unspecified 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 claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale. The plans 2022 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. We determined the enrollee was in the initial coverage stage when this tier 4 drug was purchased and was charged a 50 percent coinsurance. This drug was paid correctly and no further reimbursement is required by the plan.