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

At issue is coverage for Acetaminophen 500 milligram tablet to treat unknown diagnosis. 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 available documentation. Acetaminophen is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity 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 Moxifloxacin/Bromfenac/Prednisolone bulk powder compounded drug. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The requested drug is considered a bulk powder/ or is consistent of bulk powder ingredients and is excluded from coverage under Part D. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a consultation. 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.According to Medicare rules, the service at issue does not meet the definition of a Part D drug and is excluded from coverage under Part D. The decision does not address medical necessity. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue are injection supplies. 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.According to Medicare rules, the service at issue does not meet the definition of a Part D drug and is excluded from coverage under Part D. The decision does not address medical necessity. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is an injection. 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.According to Medicare rules, the service at issue does not meet the definition of a Part D drug and is excluded from coverage under Part D. The decision does not address medical necessity. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron 2 milligram per milliliter solution 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 submitted documentation shows the enrollee purchased drugs from a pharmacy on a cruise ship. Drugs purchased on a cruise ship are considered foreign claims outside of the United States and are excluded from coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron 8 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 submitted documentation shows the enrollee purchased drugs from a pharmacy on a cruise ship. Drugs purchased on a cruise ship are considered foreign claims outside of the United States and are excluded from coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Favorable

At issue is YF Vax injection prescribed for vaccination. 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 submitted documentation shows the enrollee received the vaccine at the prescriber's office. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or prescribers office. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement from the prescribers office and a proof of payment indicating full payment was made for the vaccine and administration fee. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Tetanus/Diphtheria vaccine. The Part D plan denied the request.We received a 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's Evidence of Coverage states, 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 documentation does not include a valid proof of purchase for the drug at issue. Therefore, the request for reimbursement cannot be granted.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage and reimbursement for Naltrexone Hydrochloride 100 percent powder prescribed as an ingredient for a compounded drug to treat the enrollees condition. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The submitted documentation indicates the requested drug was compounded from bulk powder. Therefore, the compounded drug is excluded from coverage under Part D and reimbursement cannot be allowed.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 coverage for Quinine sulfate 324 milligram oral capsule to treat leg cramps. 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 available documentation. During this review, 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.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition 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 condition. Therefore, the drug is being prescribed for a non-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 Botox 100 unit vial prescribed to treat blepharospasm associated with dystonia or strabismus. 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 available documentation. The submitted documentation shows a benefit card was applied to the purchase of the requested drug. Benefit cards are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When the enrollees benefit card was used, the enrollee acknowledged and agreed that the discount program will be treated as the primary payor with respect to the medications that are purchased through the discount program. Therefore, the plan is not required to cover or provide reimbursement for the requested drug.This decision does not address the medical necessity 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 Dorzolamide Hydrochloride ophthalmic solution prescribed for the enrollee's condition. 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 plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xarelto 20 milligram tablet 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. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Omnipod 5 G6 Pods (Gen 5) cartridge to treat the enrollees condition. 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 available documentation.Omnipod 5 is a brand product on Tier 4 of the plans non-prefered formulary. There are no brand products of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Dificid 200 milligram tablet to treat clostridium difficile colitis. 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 available documentation.Dificid is included on Tier 5 of the plans formulary. Tier 5 of the formulary is the tier reserved for specialty drugs. The Specialty tier is exempt from tiered cost-sharing expectations, per Medicare rules. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Repatha Sureclick 140 milligram per milliliter solution auto-injector to treat hyperlipidemia in an enrollee with clinical atherosclerotic cardiovascular disease. 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 available documentation. The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements have not been met. 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 coverage and reimbursement for Relion Premier Glucose meter to treat your condition. The Part D plan auto-forwarded the case to us for review.Medicare classifies home blood glucose monitors as durable medical equipment. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment. Additionally, payment will be made under Medicare Part B for the supplies necessary for the effective use of durable medical equipment, including THE ITEM. Any drug/item available for coverage under Medicare Part B cannot be covered under Part D, per Medicare rules. As such, the requested item is not eligible for Medicare Part D coverage and/or reimbursement.This decision does not address the medical necessity of the item. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit the request for coverage through Medicare Part B.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tobramycin ophthalmic suspension prescribed for prophylaxis of eye infection. 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 plan's Evidence of Coverage states, if an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The enrollee provided a pharmacy statement and a receipt indicating full payment for the requested drug. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluorouracil 5 percent cream prescribed for the enrollee's condition. 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 in the initial coverage stage when the drug was purchased at a standard pharmacy. According to the plans Evidence of Coverage, the requested drug is a tier 4 drug with a copay of $275 in the initial coverage stage for standard pharmacy. The record shows the full price of the drug was less than the $275 copay amount. Therefore, the 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 coverage for Oxycodone 30 milligram tablet to treat the enrollee's condition. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plans Evidence of Coverage states, reimbursement for drugs administered to an enrollee, are based on the amount paid for the drug, less any deductible, copayment or coinsurance, less the amount the physician charges, and the plans approved amount. The plan submitted documentation showing the enrollee was reimbursed for the plans share of the cost for the requested drug and administration fee. Therefore, we determined that the plan is not required to provide further reimbursement for dates of service January 3, 2023, February 15, 2023, April 20, 2023, May 18, 2023, and June 15, 2023.The submitted documentation shows the enrollee filled a prescription for the requested drug at a network pharmacy. 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 showing the amount that was paid for the drug was not provided. Therefore, the reimbursement criteria have not been met for dates of service February 3, 2023, February 23, 2023, and March 23, 2023,
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage of Oxycodone 40 milligram tablet prescribed for the enrollee's condition. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The submitted documentation shows the enrollee filled a prescription for the requested drug at a network pharmacy. 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 showing the amount that was paid for the drug was not provided. Therefore, the reimbursement criteria have not been met for dates of service May 13, 2023, and June 10, 2023.We determined that the plan is not required to cover the Oxycodone 40 milligram for dates of service April 14, 2023, and July 13, 2023. The National Drug Code of the requested drug is not listed with the Food and Drug Administration. Therefore, the drug is excluded from coverage under Medicare Part D. This decision does not concern 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 Oxycodone 40 milligram tablet milligram tablet prescribed for the enrollee's condition. 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 plans Evidence of Coverage states, reimbursement for drugs administered to an enrollee are based on the amount paid for the drug, less any deductible, copayment or coinsurance, less the amount the physician charges, and the plans approved amount. The plan submitted documentation showing the enrollee was reimbursed for the plans share of the cost for the requested drug. Therefore, we determined that the plan is not required to provide further reimbursement for dates of service February 16, 2023, and February 23, 2023.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Oxymorphone 20 milligram tablet prescribed for the enrollee's condition. 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 plans Evidence of Coverage states, reimbursement for drugs administered to an enrollee are based on the amount paid for the drug, less any deductible, copayment or coinsurance, less the amount the physician charges, and the plans approved amount. The plan submitted documentation showing the enrollee was reimbursed for the plans share of the cost for the requested drug. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Addyi 100 milligram tablet. 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 available documentation.The only Food and Drug Administration (FDA)-approved indication for the requested drug, Addyi, is for the treatment of premenopausal women with acquired and generalized hypoactive sexual desire disorder (HSDD) characterized by low sexual desire. Drugs prescribed to treat sexual dysfunction, such as hypoactive sexual desire disorder, are excluded from the Part D coverage. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity 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 tiering exception request for Mounjaro 12.5 milligram per 0.5 milliliter auto-injector to treat type 2 diabetes mellitus with retinopathy and macular edema. 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 available documentation.Mounjaro is included on Tier 5 of the plans formulary. Tier 5 of the formulary is the tier reserved for specialty drugs. The Specialty tier is exempt from tiered cost-sharing expectations, per Medicare rules. Therefore, this drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Humira CF (citrate free) 40 milligram per 0.8 milliliter to treat rheumatoid arthritis and nodular scleritis. 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 available documentation. The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.