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

At issue is Hydrocodone/Acetaminophen 5/325 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 Lactulose 10 gram 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 Levothyroxine Sodium 75 microgram 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 Midodrine Hydrochloride 2.5 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 Midodrine Hydrochloride 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 Omeprazole delayed release 20 milligram 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 Pregabalin 25 milligram 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 Pregabalin 50 milligram 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 Pregabalin 75 milligram 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 Seroquel 25 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 45 percent coinsurance for the tier 3 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 Tamsulosin Hydrochloride 0.4 milligram 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 Timolol Maleate 0.5 percent 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 Tramadol 50 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 Trazodone Hydrochloride 50 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 Xarelto 20 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 30 percent coinsurance for the tier 2 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 self administered drugs 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. The submitted documentation shows the enrollee requested the Part D plan to provide reimbursement for self administered drugs given while in the emergency room. However, there is missing information needed to consider the request. The required information includes the drug name, dosage, quantity, cost, the National Drug Code (NDC) of the requested drug, and the prescribing physicians name, address and National Provider Identifier (NPI) number. 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 a tiering exception request for Entresto 24-26 milligram tablet to treat non-ischemic cardiomyopathy. 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.Entresto 24-26 milligram tablet is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyproheptadine Hydrochloride 4 milligram tablet to treat seasonal allergic rhinitis. 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 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 Mybetriq extended release (ER) 25 milligram tablet to treat overactive bladder. 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.This drug is a Brand drug on Tier 3 of the plans formulary. There are no drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, it is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Combigan 0.2 percent drops prescribed for an unspecified diagnosis. The Part D plan denied the additional reimbursement 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 paid full price for the requested drug at a net-work pharmacy. 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. In this case, documentation was provided showing the plan's approved price for the drug was $222.26. The plan will only reimburse up to the contracted price of the drug, minus any deductible, copay or coinsurance. The plan provided documentation indicating the enrollee was reimbursed $177.81, which was the remaining amount after the $44.45 copay was applied. We determined that the plan calculated reimbursement correctly and is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levothyroxine Sodium 75 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the additional reimbursement 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 paid full price for the requested drug at a net-work pharmacy. 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. In this case, documentation was provided showing the plan's approved price for the drug was $11.35. The plan will only reimburse up to the contracted price of the drug, minus any deductible, copay or coinsurance. The plan provided documentation indicating the enrollee was reimbursed $0.00, which was the remaining amount after the $11.35 copay was applied. We determined that the plan calculated reimbursement correctly and is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pantoprazole Sodium 40 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the additional reimbursement 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 paid full price for the requested drug at a net-work pharmacy. 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. In this case, documentation was provided showing the plan's approved amount for the drug on date of service January 13, 2022 was $5.81. The plan will only reimburse up to the contracted price of the drug, minus any deductible, copay or coinsurance. The plan provided documentation indicating the enrollee was reimbursed $0.00, which was the remaining amount after the $5.81 copay was applied. We determined that the plan calculated reimbursement correctly and is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pantoprazole Sodium 40 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the additional reimbursement 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 paid full price for the requested drug at a net-work pharmacy. 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. In this case, documentation was provided showing the plan's approved amount for the drug on date of service January 28, 2022 was $6.68. The plan will only reimburse up to the contracted price of the drug, minus any deductible, copay or coinsurance. The plan provided documentation indicating the enrollee was reimbursed $0.00, which was the remaining amount after the $6.68 copay was applied. We determined that the plan calculated reimbursement correctly and is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Shingrix 50 microgram (mcg) per 0.5 milliliter (ml) for suspension 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, including the case file from the plan, and any information submitted at the reconsideration level.Shingrix is a biologic on Tier 3 of the plans formulary. There are no biologic of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this biologic is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.