Persius/hicric huggingface dataset:
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 enrollees request for additional reimbursement.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 claims for the requested drug were approved and copayments were charged correctly to the enrollee at the point of sale for dates of fill May 24, 2021 and August 4, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage when this tier 1 drug was purchased on May 24, 2021 and August 4, 2021. Therefore, we determined the copays charged were correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rosuvastatin Calcium 10 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.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 claims for the requested drug were approved and copayments were charged correctly to the enrollee at the point of sale for dates of fill April 23, 2021 and July 9, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage when this tier 1 drug was purchased on April 23, 2021 and July 9, 2021. Therefore, we determined the copays charged were correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Venlafaxine Hydrochloride 75 milligram extended release 24 hour capsule prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.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 claims for the requested drug were approved and copayments were charged correctly to the enrollee at the point of sale for dates of fill February 3, 2021 and March 22, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the initial coverage cost share stage when the tier 2 drug was purchased on February 3, 2021 and in the coverage gap cost share stage on date of purchase March 22, 2021. Therefore, we determined the copays charged were correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Abiraterone Acetate 250 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. The submitted documentation shows a discount card was applied to the purchase 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 SingleCare benefit card was used, the enrollee acknowledged and agreed that the SingleCare discount program will be treated as the primary payor with respect to the medications that are purchased through the SingleCare discount program. Therefore, the plan is not required to cover or provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Quetiapine Fumarate 300 milligram tablet to treat 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, including the case file from the plan, and any information submitted at the reconsideration level. Quetiapine Fumarate is a generic drug on Tier 3 of the plans formulary. There are no generic 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 Boostrix 5/2.5/18.5 microgram/0.5 milliliter syringe 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 reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan submitted documentation showing the claim from the prescribing physician was approved and payment was issued to the physician, minus the enrollee's copay of $47.00 for the tier 3 vaccine provided at an out-of-network prescriber's office. Medicare Part B covers the requested vaccine when it is administered to prevent infection as a result of an injury or wound. The documentation does not indicate the vaccine was given for that reason. Therefore, the Part D plan processed the claim correctly and further reimbursement to the enrollee is not required.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lisinopril 40 milligram tablet 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 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 plans Evidence of Coverage states, limits and restrictions are placed on drugs that are refilled too soon. The submitted documentation shows the enrollee purchased a 90 day supply of the requested drug on April 22, 2022. Therefore, the claim for fill date June 1, 2022 was rejected at point of sale for refill too soon, and the amount charged to the enrollee was an out-of-pocket expense. 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 Tetanus Diphtheria Pertussis (TDAP) vaccine prescribed for vaccination. 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 vaccine was provided by the prescriber and administered in the prescribers office. The plan's 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. However, proof of payment by the enrollee in the form of a receipt was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Endur-Acin extended release 250 milligram tablet. 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 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 BinaxNow COVID-19 Antigen At Home Test. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The requested test kit is considered a non-prescription product and does not meet the definition of a Part D drug. Therefore, the requested product is excluded from coverage under the Part D benefit and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lucira Check It COVID-19 Antigen Home Test Kit. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The requested test kit is considered a non-prescription product and does not meet the definition of a Part D drug. Therefore, the requested product is excluded from coverage under the Part D benefit and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydromorphone 5 milligram per 6 milliliter 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 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 GoodRX discount card was applied to the purchase 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 GoodRX benefit card was used, the enrollee acknowledged and agreed that the GoodRX discount program will be treated as the primary payor with respect to the medications that are purchased through the GoodRX discount program. Therefore, the plan is not required to cover or provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Shingrix vaccine 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 facility. 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 credit card receipt showing payment was made for less than the full amount charged for the vaccine. However, the statement indicates a portion of the charge was written off and the enrollee' s balance is now $0. Therefore, we determined the reimbursement criteria have been met and the plan is required to provide reimbursement, based on the amount paid by the enrollee and the enrollee's cost share stage at the time the vaccine was administered.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Synjardy 12.5/1000 milligram tablet to treat type 2 diabetes mellitus. 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. Synjardy is a brand drug on Tier 2 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 a tiering exception request for Epinephrine 0.3 milligram per 0.3 milliliter solution auto-injector to treat anaphylaxis due to bee sting allergy. 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. Epinephrine is a generic drug on Tier 3 of the plans formulary. There are no generic 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 Cosopt preservative free 2/0.5 percent solution to treat glaucoma. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The requested drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Adacel 5/2/15.5 microgram/0.5 milliliter suspension prescribed for vaccination. 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 vaccine was provided by the prescriber and administered in the prescribers office. The plan's 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. However, proof of payment by the enrollee in the form of a receipt was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jublia 10 percent topical solution to treat tinea unguium. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5 milligram tablet to reduce risk of stroke and systemic embolism associated with atrial fibrillation. 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 being provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Adhansia extended release 85 milligram capsule. The Part D plan denied the request as an excluded drug in the Medicare Part D program.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.For the drug at issue to be covered under Medicare Part D, the manufacturer must participate in the Medicare Coverage Gap Discount Program. This manufacturer is not participating in the program; therefore, the drug is excluded from Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Finasteride 1 milligram tablet to treat nonscarring hair loss. 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 to promote hair growth (or treat hair 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 Sodium Chloride 7 percent vial. The case was auto-forwarded by the plan. We received the submitted documentation to perform an independent and de novo review. The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a 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: Favorable

At issue is Dalfampridine extended release 10 milligram tablet to treat multiple sclerosis. 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. The documentation satisfies the plans coverage criteria. The request is for a new start. The enrollee has a diagnosis of one of the four types of multiple sclerosis (Relapse-Remitting, Primary-Progressive, Secondary-Progressive, Progressive Relapsing). The enrollee is ambulatory. The enrollee has had an initial timed 25-foot walk (T25W) test or another objective measure of gait that provides evidence of significant walking impairment related to multiple sclerosis. The enrollee does not have a history of seizure disorder. The enrollee does not have moderate to severe renal impairment. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trulicity 75 milligrams per 0.5 milliliter to treat type II diabetes mellitus. 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, including the case file from the plan, and any information submitted at the reconsideration level. This drug is a biologic 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 Zoledronic Acid 5 milligrams per 100 milliliters to treat osteoporosis. 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 Buprenorphine Hydrochloride 2 milligram sublingual tablet to treat spondylolysis, lumbosacral region. 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(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 Forteo 20 microgram per dose pen injector to treat glucocorticoid-induced osteoporosis. 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.We cannot consider a quantity limit exception for a drug for which the Medicare Part D plan is unable to provide coverage. Therefore, the plan is not required to cover Forteo or to grant a quantity limit exception for this drug.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 Armour Thyroid 30 milligram tablet to treat hypothyroidism. 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 that are not approved by the Food and Drug Administration (FDA) are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.