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

At issue is a tiering exception request for Xifaxan 550 milligram tablet to treat irritable bowel syndrome with diarrhea. 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 a tiering exception request for Desvenlafaxine Succinate 24 hour extended release 50 milligram tablet to treat depression. 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.Desvenlafaxine Succinate extended release 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.A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nebivolol 5 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request for additional reimbursement. We received a 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 in the coverage gap stage when the requested drug was purchased. According to the plans Evidence of Coverage, during the coverage gap stage the enrollee pays 25% of the price for brand name drugs. The information provided shows the plan paid its share of the cost for the requested drug, and the enrollees cost share was calculated based on 25% of the remaining amount after the coverage gap discount was applied. 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 reimbursement for Glucotrol extended release 2.5 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 for date of fill February 18, 2022 shows the cost of the drug was more than the plan approved amount. The claim information for date of fill April 1, 2022 was denied as refilled too soon, as there was a paid claim already on file for April 11, 2022. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 100 gram powder prescribed for an unspecified diagnosis. 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.The submitted documentation includes a reimbursement request form and Universal Claim Form for Compounded Medication. 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 provided documentation does not include the National Drug Code (NDC) for the requested drug. Therefore, we determined that the reimbursement criteria are not met for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amlodipine 10 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 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 Center for Medicare and Medicaid Services (CMS) requires that Medicare Part D plans verify pharmacy claims with the National Council for Prescription Drug Programs (NCPDP). The submitted documentation does not include the prescriber's NCPDP unique identifier number assigned to their facility or the prescriber's National Provider Identifier (NPI) number. Therefore, the plan is not required to cover or provide reimbursement for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gabapentin 300 milligram capsule 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 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 Center for Medicare and Medicaid Services (CMS) requires that Medicare Part D plans verify pharmacy claims with the National Council for Prescription Drug Programs (NCPDP). The submitted documentation does not include the prescriber's NCPDP unique identifier number assigned to their facility or the prescriber's National Provider Identifier (NPI) number. Therefore, the plan is not required to cover or provide reimbursement for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Loratadine 10 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 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 Center for Medicare and Medicaid Services (CMS) requires that Medicare Part D plans verify pharmacy claims with the National Council for Prescription Drug Programs (NCPDP). The submitted documentation does not include the prescriber's NCPDP unique identifier number assigned to their facility or the prescriber's National Provider Identifier (NPI) number. Therefore, the plan is not required to cover or provide reimbursement for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Losartan 50 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 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 Center for Medicare and Medicaid Services (CMS) requires that Medicare Part D plans verify pharmacy claims with the National Council for Prescription Drug Programs (NCPDP). The submitted documentation does not include the prescriber's NCPDP unique identifier number assigned to their facility or the prescriber's National Provider Identifier (NPI) number. Therefore, the plan is not required to cover or provide reimbursement for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omeprazole 20 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 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 Center for Medicare and Medicaid Services (CMS) requires that Medicare Part D plans verify pharmacy claims with the National Council for Prescription Drug Programs (NCPDP). The submitted documentation does not include the prescriber's NCPDP unique identifier number assigned to their facility or the prescriber's National Provider Identifier (NPI) number. Therefore, the plan is not required to cover or provide reimbursement for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone 5 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 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 Center for Medicare and Medicaid Services (CMS) requires that Medicare Part D plans verify pharmacy claims with the National Council for Prescription Drug Programs (NCPDP). The submitted documentation does not include the prescriber's NCPDP unique identifier number assigned to their facility or the prescriber's National Provider Identifier (NPI) number. Therefore, the plan is not required to cover or provide reimbursement for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Potassium Chloride 20 milliequivalent 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 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 Center for Medicare and Medicaid Services (CMS) requires that Medicare Part D plans verify pharmacy claims with the National Council for Prescription Drug Programs (NCPDP). The submitted documentation does not include the prescriber's NCPDP unique identifier number assigned to their facility or the prescriber's National Provider Identifier (NPI) number. Therefore, the plan is not required to cover or provide reimbursement for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pramipexole 0.25 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 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 Center for Medicare and Medicaid Services (CMS) requires that Medicare Part D plans verify pharmacy claims with the National Council for Prescription Drug Programs (NCPDP). The submitted documentation does not include the prescriber's NCPDP unique identifier number assigned to their facility or the prescriber's National Provider Identifier (NPI) number. Therefore, the plan is not required to cover or provide reimbursement for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pravastatin 10 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 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 Center for Medicare and Medicaid Services (CMS) requires that Medicare Part D plans verify pharmacy claims with the National Council for Prescription Drug Programs (NCPDP). The submitted documentation does not include the prescriber's NCPDP unique identifier number assigned to their facility or the prescriber's National Provider Identifier (NPI) number. Therefore, the plan is not required to cover or provide reimbursement for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Solifenacin 5 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 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 Center for Medicare and Medicaid Services (CMS) requires that Medicare Part D plans verify pharmacy claims with the National Council for Prescription Drug Programs (NCPDP). The submitted documentation does not include the prescriber's NCPDP unique identifier number assigned to their facility or the prescriber's National Provider Identifier (NPI) number. Therefore, the plan is not required to cover or provide reimbursement for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prednisolone/Moxifloxacin/Nepafenac 1/0.5/0.1 percent eye drops prescribed for cataract surgery. The Part D plan auto-forwarded the enrollees 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.We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the ingredients for this compound are not approved as safe and effective. Therefore, we determined that the plan is not required to cover or provide reimbursement for the requested compounded drug. 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 reimbursement for Insulin Lispro Kwikpen U-100 to treat diabetes. 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 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 not have been 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 Diltiazem 2 percent ointment prescribed for 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. 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 submitted documentation shows the National Drug Code (NDC) for Diltiazem is missing from the Universal Claim Form for a Compounded Medication. Therefore, coverage and reimbursement cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent ointment prescribed for 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. We determined that the plan is not required to cover the requested compounded drug. The submitted documentation shows the National Drug Code (NDC) for Lidocaine 5 percent ointment is not approved by the Food and Drug Administration (FDA). Therefore, the drug is excluded from coverage under Medicare Part D and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Omeprazole delayed release 40 milligram capsule 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 a request for coverage of Lyrica 300 milligram capsules to treat neuropathic pain in the legs and feet due to lumbar spondylosis and/or small fiber neuropathy. Also at issue is a request for reimbursement for the drug that has already been purchased. The Part D plan denied both requests. 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 noted conditions are off-label uses for the requested drug. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. Therefore, the drug is being prescribed for non-medically accepted indications and is not eligible for Part D coverage. Since the drug is not eligible for coverage, reimbursement for the drug already purchased is also not covered.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 Vitamin D2 1250 microgram capsule 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 reimbursement for Ibandronate Sodium 150 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 reimbursement for Levothyroxine Sodium 88 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 Piperacillin Sodium/Tazobactam Sodium 13.5 gram intravenous solution to treat an infection of a prosthetic joint. 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 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 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 Aimovig 140 milligram per milliliter auto injector prescriber #140 per 30 days to treat unspecified headaches. 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.A request was submitted to the prescriber to provide a diagnosis, the quantity prescribed was medically necessary for the enrollee, and to provide supporting medical records. A reply from the prescriber was not received. 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.The plan limits the amount of Aimovig to 1 injection per 28 days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the diagnosis or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.