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

At issue is coverage for Otezla 30 milligram tablets to treat psoriasis vulgaris. 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.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for reimbursement for Tetanus, Diphtheria and Pertussis (TDAP) vaccine. 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 received the vaccine at the prescriber's office. The plans 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. The submitted information includes a receipt from the prescriber's office indicating full payment was made for the vaccine and administration fee. The plan provided information including a valid National Drug Code and the prescriber's National Provider Identifier number. Therefore, we determined the plan is required to provide reimbursement based on the enrollee's cost share stage on the date of vaccination.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for reimbursement for Yellow Fever vaccine. 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 received the vaccine at the prescriber's office. The plans 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. The submitted information includes a receipt from the prescriber's office indicating full payment was made for the vaccine and administration fee. The plan provided information including a valid National Drug Code and the prescriber's National Provider Identifier number. Therefore, we determined the plan is required to provide reimbursement based on the enrollee's cost share stage on the date of vaccination.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ciclopirox 8 percent solution 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 enrollee used their benefit card, and the claim was paid at the point of service on February 6, 2023. The enrollee was in the Initial Coverage benefit stage. The enrollee paid $27.79 the entirety of which was applied to the enrollees copay and or deductible.The submitted documentation shows the plan processed the claim 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 applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Neomycin/Polymyxin/Hydrocortisone 3.5/10K/1 suspension 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 enrollee used their benefit card, and the claim was paid at the point of service on February 6, 2023. The enrollee was in the Initial Coverage benefit stage. The enrollee paid $47.00 the entirety of which was applied to the enrollees copay and or deductible.The submitted documentation shows the plan processed the claim 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 applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Opsumit 10 milligram tablets to treat unspecified pulmonary hypertension. 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. 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 Prednisolone Acetate/Moxifloxacin/Bromfenac 1/0.5/0.375 precent suspension prescribed for cataract surgery. 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. This includes the case file from the plan, and any information submitted at the reconsideration level.This compound is not on the plan formulary and was not approved by plan. The requested compounded product does not meet the definition of a Part D drug as defined by Medicare.The plan provided documentation showing the enrollee requested coverage for compounded eye drops. 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 Tramadol Hydrochloride powder prescribed for an unknown diagnosis. The Part D plan denied the request and then auto-forwarded the case to us for review.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 requested the Part D plan to provide reimbursement for the requested drug. However, there is missing information needed to consider the request. The required information includes the Pharmacy name, drug name with quantity, pharmacy receipt indicating the enrollee paid for the drug, and the prescribing physicians name, address and National Provider Identifier (NPI) number were submitted. The National Drug Code (NDC) of the requested drug is not documented on any of the submitted information, including the pharmacy prescriptions. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Celebrex 200 milligram capsules to treat polyosteoarthritis. 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: Partially Favorable

You requested Amlodipine Besylate 5 milligram tablets. The Part D 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 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. The record shows the plan reprocessed your claim for the Amlodipine Besylate tablets and adjusted the amount due to your true out of pocket (TrOOP) accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan is responsible for owing you $1.97. We have determined that the plan is correct in its calculation of your reimbursement copay as noted.
Appeal type: Prescription Drug
Decision: Partially Favorable

You requested Anastrozole 1 milligram tablets. The Part D 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 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. The record shows the plan reprocessed your claim for the Anastrozole tablets and adjusted the amount owed due to your true out of pocket (TrOOP) accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, you are responsible for the remaining balance of $7.82. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Partially Favorable

You requested Methimazole 5 milligram tablets. The Part D 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 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. The record shows the plan reprocessed your claim for the Methimazole tablets and adjusted the amount owed due to your true out of pocket (TrOOP) accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, you are responsible for the remaining balance of $8.84. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Partially Favorable

You requested Myrbetriq 50 milligram tablets. The Part D 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 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. The record shows the plan reprocessed your claim for the Myrbetriq tablets and adjusted the amount owed due to your true out of pocket (TrOOP) accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, you are responsible for the remaining balance of $5.80. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Partially Favorable

You requested Valsartan 320 milligram tablets. The Part D 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 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. The record shows the plan reprocessed your claim for the Valsartan tablets and adjusted the amount owed due to your true out of pocket (TrOOP) accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, you are responsible for the remaining balance of $5.35. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pantoprazole Sodium delayed release 40 milligram tablets. The Part D 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 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. The record shows the plan reprocessed your claim for the Pantoprazole Sodium delayed release tablets and adjusted the amount owed due to your true out of pocket (TrOOP) accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, you are responsible for the remaining balance of $6.45. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Biest 80/20 percent hormonal cream. The Part D plan auto-forwarded the case to us for reviewWe 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 has requested the Part D plan to provide reimbursement for the requested drug. However, there is missing information needed to consider the request. The submitted documentation does not include a reimbursement claim form that lists the National Drug Code (NDC) for the requested drug and the prescribing physicians name, address, and National Provider Identifier (NPI) number. Therefore, the reimbursement requirements have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sodium Sulfate/Potassium Sulfate/Magnesium Sulfate 17.5/3.13/1.6 gram per 117 milliliter prescribed for a colonoscopy bowel preparation. 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 plan submitted documentation that shows the enrollee was in the initial coverage stage of the Part D benefit when this drug was purchased. The off-formulary drug was paid as a transition fill. 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 copayment/coinsurance amount that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Engerix B 20 microgram per milliliter syringe for Hepatitis B vaccination. The Part D plan auto-forwarded the case to us for reviewWe 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 record shows the enrollee purchased Engerix B at a network pharmacy on April 3, 2023, for $108.99. The plans 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. The plans formulary shows the drug is covered as a Tier 3 drug. The documentation submitted includes evidence the drug is covered by the plan and only reimbursement is at issue. A receipt showing payment for the drug, a valid National Drug Code, and confirmation the drug was purchased at a network pharmacy were submitted. The enrollee had active coverage and the drug is on the plans formulary. Therefore, we determined that the plan is required to reimburse the enrollee the cost of Engerix B minus any amounts due for a deductible or copay.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for reimbursement for Estriol 1 milligram per milliliter cream. 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 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. The submitted information includes a receipt indicating full payment was made for the drug. In addition, the submitted documentation includes a valid National Drug Code (NDC) for the requested drug and the prescriber's National Provider Identifier (NPI) number. Therefore, the reimbursement requirements have been met and reimbursement for the drug is supported.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydrocodone/Acetaminophen 5/325 milligram tablets. The Part D 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 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. The record shows the plan reprocessed your claim for the Hydrocodone/Acetaminophen 5/325 milligram tablets and adjusted the amount owed due to your true out of pocket (TrOOP) accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, you are responsible for the remaining balance of $5.36. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is HZV and Administration Fee prescribed for vaccination. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we 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.The plan submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the vaccine was administered. The plans Evidence of Coverage states that enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined the amount the enrollee paid was applied to the deductible and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Mycophenolate Acid delayed release 360 milligram tablet prescribed for a liver and kidney transplant rejection prophylaxis. 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. Additionally, we researched Medicare systems.Medicare systems show that the enrollee was eligible for Medicare Part A coverage from March 1, 2022, to present. Therefore, the enrollee was eligible for Medicare Part A coverage when undergoing a liver and kidney transplant on October 6, 2022. If the enrollee was eligible for Medicare Part A coverage on the date of the transplant, immunosuppressive drugs prescribed for transplant rejection prophylaxis would be covered under Medicare Part B. Medicare rules state that any drug available for coverage under Medicare Part B cannot be covered under Part D. Therefore, the requested drug is not eligible for 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. Please submit the request for coverage through Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Tacrolimus 1 milligram capsule prescribed for a liver and kidney transplant rejection prophylaxis. 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. Additionally, we researched Medicare systems.Medicare systems show that the enrollee was eligible for Medicare Part A coverage from March 1, 2022, to present. Therefore, the enrollee was eligible for Medicare Part A coverage when undergoing a liver and kidney transplant on October 6, 2022. If the enrollee was eligible for Medicare Part A coverage on the date of the transplant, immunosuppressive drugs prescribed for transplant rejection prophylaxis would be covered under Medicare Part B. Medicare rules state that any drug available for coverage under Medicare Part B cannot be covered under Part D. Therefore, the requested drug is not eligible for 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. Please submit the request for coverage through Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Benztropine Mesylate 1 milligram tablet, 90 tablets per 90 days, to treat extrapyramidal and movement disorder, unspecified. 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 indicate 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.