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

At issue is coverage for an Omnipod 5 G6 (Gen 5) introductory kit to treat type 1 diabetes mellitus. The plan denied the request for coverage and then 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 documentation submitted.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that all formulary alternatives were tried and failed, or were contraindicated. The prescriber did not respond to the request.Omnipod 5 G6 (Gen 5) introductory kit is not on the plans formulary. In order to grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed, or deemed contraindicated. In this case, the documentation does not support why the formulary alternatives listed by the plan would likely not be as effective for this diagnosis and/or would likely cause adverse reactions 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 Lidocaine 5 percent patch to treat chronic back pain. 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. However, we did not receive the requested information.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 Lidocaine 5 percent patch to treat spondylosis, and low back pain. 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.No documentation was provided by the prescriber to support these diagnoses. We requested information from the prescriber but no information was received. We are not able to determine whether the requested drug(s) was prescribed for a medically accepted indication. Therefore, the 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 Lidocaine 5 percent patch to treat chronic right-sided thoracic back pain. 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 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 Eliquis 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. 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 outside of the United States. Drugs purchased outside of the United States 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 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. 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 outside of the United States. Drugs purchased outside of the United States 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 Novalgin 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. 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 outside of the United States. Drugs purchased outside of the United States 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 Oxycodone Hydrochloride extended release 10 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 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 a discount card was applied to the purchases of the requested drug. Discount 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 Oxycodone on the dates of purchase requested.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anucort Hydrocortisone Acetate 25 milligram suppository 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, including the case file from the plan, and any information submitted at the reconsideration level.The plan denied the request for coverage because drugs classified as part of the Food and Drug Administrations (FDAs) Drug Efficacy Study Implementation program cannot be covered by the Medicare Part D drug benefit. These drugs are considered to be less than effective per FDA review. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amlodipine 10 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 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. Medicare records show the enrollee was not enrolled with the Part D plan on dates of purchase January 13, 2022, January 27, 2022 and February 25, 2022. Therefore, we determined that the plan is not required to provide coverage or reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aspirin 81 milligram tablet. 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 and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Atorvastatin 40 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 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. Medicare records show the enrollee was not enrolled with the Part D plan on dates of purchase January 13, 2022, January 27, 2022 and February 24, 2022. Therefore, we determined that the plan is not required to provide coverage or reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bisoprolol Fumarate 10 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 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. Medicare records show the enrollee was not enrolled with the Part D plan on dates of purchase January 13, 2022, January 27, 2022 and February 25, 2022. Therefore, we determined that the plan is not required to provide coverage or reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Donepezil 10 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 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. Medicare records show the enrollee was not enrolled with the Part D plan on dates of purchase January 13, 2022, January 27, 2022, February 11, 2022 and March 10, 2022. Therefore, we determined that the plan is not required to provide coverage or reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dorzolamide 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 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. Medicare records show the enrollee was not enrolled with the Part D plan on dates of purchase January 21, 2022 and March 21, 2022. Therefore, we determined that the plan is not required to provide coverage or reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 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 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. Medicare records show the enrollee was not enrolled with the Part D plan on dates of purchase January 13, 2022, January 27, 2022 March 11, 2022 and March 24, 2022. Therefore, we determined that the plan is not required to provide coverage or reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Furosemide 40 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 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. Medicare records show the enrollee was not enrolled with the Part D plan on dates of purchase January 27, 2022 and February 11, 2022. Therefore, we determined that the plan is not required to provide coverage or reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latanoprost 0.005 percent 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 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. Medicare records show the enrollee was not enrolled with the Part D plan on dates of purchase January 11, 2022, February 17, 2022 and March 21, 2022. Therefore, we determined that the plan is not required to provide coverage or reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Losartan Potassium 100 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 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. Medicare records show the enrollee was not enrolled with the Part D plan on dates of purchase January 13, 2022, January 27, 2022 and February 25, 2022. Therefore, we determined that the plan is not required to provide coverage or reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Memantine Hydrochloride 10 milligram tablet 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 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. Medicare records show the enrollee was not enrolled with the Part D plan on dates of purchase January 27, 2022 and February 11, 2022. Therefore, we determined that the plan is not required to provide coverage or reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pantoprazole 40 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 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. Medicare records show the enrollee was not enrolled with the Part D plan on dates of purchase January 13, 2022, January 27, 2022 and February 25, 2022. Therefore, we determined that the plan is not required to provide coverage or reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sertraline 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 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. Medicare records show the enrollee was not enrolled with the Part D plan on dates of purchase January 13, 2022, January 27, 2022 and February 25, 2022. Therefore, we determined that the plan is not required to provide coverage or reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluorouracil 500 milligram per 10 milliliter solution to treat conjunctival intraepithelial neoplasia. 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 Mounjaro 5 milligram per 0.5 milliliter injection to treat weight gain. 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, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed to treat weight gain (promote weight loss) 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 reimbursement for Betahistine 16 milligram capsules. 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 provided claim information for the enrollee indicating the drug at issue was dispensed at a pharmacy not in the plans network on the date the prescription was filled. In these instances, the enrollee may be responsible for paying the difference between what he/she pays for the drug at the out of network pharmacy and the cost that the plan would cover at an in network pharmacy. We determined that the plan is not required to reimburse you for Betahistine 16 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Virt-Phos Neutral 250 milligram tablet to treat abnormal level of blood mineral. 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 for use as vitamins and minerals are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage. However, the plan indicates that the requested drug is covered under the enrollee's supplemental wrap benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dorzolamide Hydrochloride/Timolol Maleate 22.3/6.8 milligram per milliliter ophthalmic solution 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.The submitted documentation shows the enrollee was given the requested drug while in a hospital outpatient stay. Self-administered drugs are processed as out-of-network benefits and reimbursement is based on the difference in what the hospital out-of-network pharmacy charges and what the plan approves, minus the enrollee's deductible, copayment or coinsurance. The plan submitted claim information showing the reimbursement was based on the enrollee's cost share of 20 percent coinsurance for the tier 1 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 Duloxetine Hydrochloride 60 milligram coated pellet capsule 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.The submitted documentation shows the enrollee was given the requested drug while in a hospital outpatient stay. Self-administered drugs are processed as out-of-network benefits and reimbursement is based on the difference in what the hospital out-of-network pharmacy charges and what the plan approves, minus the enrollee's deductible, copayment or coinsurance. The plan submitted claim information showing the reimbursement was based on the enrollee's cost share of 20 percent coinsurance for the tier 1 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 Finasteride 5 milligram tablet 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.The submitted documentation shows the enrollee was given the requested drug while in a hospital outpatient stay. Self-administered drugs are processed as out-of-network benefits and reimbursement is based on the difference in what the hospital out-of-network pharmacy charges and what the plan approves, minus the enrollee's deductible, copayment or coinsurance. The plan submitted claim information showing the reimbursement was based on the enrollee's cost share of 20 percent coinsurance for the tier 1 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 Flecainide Acetate 100 milligram tablet 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.The submitted documentation shows the enrollee was given the requested drug while in a hospital outpatient stay. Self-administered drugs are processed as out-of-network benefits and reimbursement is based on the difference in what the hospital out-of-network pharmacy charges and what the plan approves, minus the enrollee's deductible, copayment or coinsurance. The plan submitted claim information showing the reimbursement was based on the enrollee's cost share of 20 percent coinsurance for the tier 1 drug. We determined this drug was paid correctly and no further reimbursement is required by the plan.