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

At issue is Diclofenac Sodium 3 percent gel to treat an unknown condition. The case was auto-forwarded by the Part D plan. 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 a medically accepted indication, medical records, and a prescriber statement to support that all formulary alternatives were tried and failed or were contraindicated. However, we did not receive the requested information.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. We requested information from the prescriber but no information was received. We are not able to determine whether the requested drug was prescribed for a medically accepted indication. Therefore, the drug 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 Eliquis 5 milligram tablet to treat deep vein thrombosis and pulmonary embolism. 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. However, we did not receive the requested information.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 Tolvaptan 30 milligram tablet to treat hyponatremia. The case was auto-forwarded by the plan.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 the enrollee has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.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 Insulin Aspart 100 unit per milliliter solution to treat type 2 diabetes mellitus with diabetic neuropathy, unspecified. The case was auto-forwarded by the case. 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. However, we did not receive the requested information.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 Alvesco 80 microgram per actuation aerosol solution to treat asthma. 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. However, we did not receive the requested information.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 Olopatadine Hydrochloride 0.2 percent ophthalmic solution. 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 prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zovirax 5 percent cream to treat recurrent herpes labialis in an immunocompromised enrollee. 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 the enrollee has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.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 Onglyza 5 milligram tablet to treat type 2 diabetes mellitus. 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.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. Please note, this reconsideration decision was based on the plans 2023 coverage criteria.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 Zolpidem Tartrate extended release 12.5 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the 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 enrollee requested reimbursement for the Zolpidem Tartrate due to paying full price at the time of purchase. The plan provided documentation showing the claim for the requested drug was approved and reimbursement was provided, based on the plan's approved amount of $18.30 minus the enrollee's copay in the initial coverage stage of $3.60. We determined the plan's calculation of the enrollee's reimbursement of $14.70 was correct and no further reimbursement is due.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prednisolone Acetate 1 percent, Moxifloxacin 0.5 percent, Bromfenac Sodium 0.075 percent compound eye drops 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. 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 requested drug is consistent of bulk powder ingredients and is excluded from coverage under Part D and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tetanus Diphtheria and Pertussis (TDAP) 0.5 milliliter suspension prescribed for vaccination. 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 vaccine was provided by the prescriber and administered in the prescribers office. The plan's Evidence of Coverage states, that 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. However, proof of payment by the enrollee 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 a tiering exception request for Tramadol Hydrochloride 50 milligram tablet to treat fibromyalgia and osteoarthritis. 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 lower-tier drugs to treat the enrollees condition were tried and failed or were contraindicated. We received additional documentation and included it in the review.Tramadol Hydrochloride 50 milligram tablet is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug. Therefore, this drug is not eligible for a tiering exception. Please note, this reconsideration decision was based on the plans 2023 coverage criteria.A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for the Shingrix vaccine prescribed for shingles prophylaxis. The Part D plan denied the request.We requested 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.Medicare rules state that drug claims must include a valid National Drug Code (NDC) that is listed with the Food and Drug Administration (FDA). The claim form submitted includes NDC 58160-0828-11 for the Shingrix vaccine. However, this code is not listed with the FDA as a valid NDC. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is reimbursement for Dextroamphetamine/Amphetamine 25 milligram extended release capsules for a 7 day supply and total of 14 capsules. The Part D plan indicated this was an emergency 7 day fill due to a mail order back order which was approved by the plan. The plan states they have approved reimbursement of $7.13 and a check was sent to the enrollee. The decision on appeal was not made timely and the case was auto-forwarded by the plan.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 provided documentation showing this claim was approved at the time of purchase for a 7 day supply of the drug. However, the co-pay of $.91 applied for the 7 day supply and reimbursement of $7.13 was not correct. The plan must apply cost-sharing by multiplying the applicable daily cost sharing rate by the days supply actually dispensed when the enrollee receives less than the approved months supply. Therefore, we determined the plans reimbursement of $7.13 is not correct and additional reimbursement is due.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Polio Virus Vaccine Inactivated (IPOL) injection prescribed for vaccination. 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 the vaccine at an emergency clinic. 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 submitted information includes a statement from the clinic indicating full payment was made for the vaccine and administration fee. The information provided also shows a valid National Drug Code (NDC) and the prescriber's National Provider Identifier (NPI) number. Therefore, the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is TYPHIM VI 25 microgram per 0.5 milliliter solution prefilled syringe prescribed for vaccination. 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 the vaccine at an emergency clinic. 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 submitted information includes a statement from the clinic indicating full payment was made for the vaccine and administration fee. The information provided also shows a valid National Drug Code (NDC) and the prescriber's National Provider Identifier (NPI) number. Therefore, the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estriol Testosterone Hormone 0.5 percent Replacement Therapy (HRT) base cream compound 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. 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 requested drug is consistent of bulk powder and bulk ingredients and is excluded from coverage under Part D and not eligible for reimbursement. 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 reimbursement for Tdap (Adacel) vaccine. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we read 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 documentation submitted includes a receipt for a Tdap vaccine for the date of September 22, 2022. The drug is on the plans formulary with no prior authorization requirements. A receipt was provided for the vaccine given on September 22, 2022. The documentation is sufficient for reimbursement. Therefore, reimbursement can be made for $69.00 for the Tdap vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 150 milligram capsule. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. According to the plans Evidence of Coverage, Pregabalin 150 milligram capsule is on tier 2 of the plans formulary with a copay of $10, in the initial coverage stage. The record shows the full price of the drug was $4.82 which is less than the $10 copay amount. Therefore, the enrollees charge was based on the total cost of the drug. 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 Oxycodone/Acetaminophen 10 milligram/325 milligram tablet. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. According to the plans Evidence of Coverage, Oxycodone/Acetaminophen tablets are on tier 3 of the plans formulary with a copay of $47, in the initial coverage stage. The record shows the full price of the drug was $2.76 which is less than the $47 copay amount. Therefore, the enrollees charge was based on the total cost of the drug. 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 Vancomycin Hydrochloride/Sterile Water for injection/Sodium Chloride compound injection prescribed for 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 furnished Incident To a physicians service are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement. However, the plan indicates that the requested compound drug is approved for coverage under Medicare Part B. Contact your Part B plan directly to learn more about how coverage will be provided.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amitriptyline Hydrochloride 25 milligram tablet to treat unknown 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.The submitted documentation does not support a prescribed diagnosis for the drug at issue. At redetermination, the prescriber indicated a diagnosis of neuropathic pain. On appeal, the prescriber has indicated the enrollee is not using the drug for neuropathic pain. There is no indication of a prescribed diagnosis, and a request for information did not solicit further documentation. 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 a request for coverage of Hydrocortisone/Lactose 5 milligram compounded capsule to treat mast cell activation syndrome. 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, including the case file from the plan and any information submitted at the reconsideration level.The requested drug is a compound drug made with bulk powders. Bulk powders do not satisfy the definition of a Part D drug and are excluded from Part D coverage. Therefore, the Hydrocortisone/Lactose 5 milligram compounded capsule is not eligible for coverage under Medicare Part D. This decision does not address the medical necessity or appropriateness 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 a request for coverage of Hydrocortisone powder to treat mast cell activation syndrome. 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, including the case file from the plan and any information submitted at the reconsideration level.The requested drug is a bulk powder. Bulk powders do not satisfy the definition of a Part D drug and are excluded from Part D coverage. Therefore, the Hydrocortisone powder is not eligible for coverage under Medicare Part D. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.