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

At issue is coverage for Privigen 20 gram injection to treat small fiber neuropathy, other specified polyneuropathies and hereditary idiopathy neuropathy. 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 noted condition is an off-label use for the requested drug. 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: Favorable

At issue is coverage for Epclusa 400/100 milligram tablet to treat hepatitis C, genotype 2, treatment naive, without cirrhosis, in a patient without prior transplant. 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 supports that all of the plans requirements for coverage have been satisfied. Specifically, at reconsideration, the provider clarified that the patient is treatment naive and has not received a transplant. Therefore, the plans prior authorization requirements have been met and coverage for the drug is supported.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 coverage for Adbry 150 milligram per milliliter injection to treat moderate to severe atopic dermatitis. 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: Favorable

At issue is coverage for Testosterone 12.5 milligram per 1.25 gram (1 percent) gel metered dose pump to treat primary hypogonadism. 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 supports that all of the plans requirements for coverage have been satisfied. Specifically, there is documentation of a low testosterone level prior to treatment and persistent signs and symptoms including decreased stamina, gynecomastia, decreased muscle and low libido. Therefore, the plans prior authorization requirements have been met and coverage for the drug is supported.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 coverage for Opzelura 1.5 percent cream. 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 diagnosis initially provided to the plan for the requested drug was dermatitis, unspecified, pruritus. However, 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. At reconsideration, a new diagnosis of atopic dermatitis has been noted. Medical records have been submitted to validate this additional diagnosis. The use of the requested drug to treat the noted condition is a medically accepted indication for the drug as outlined in the Medicare approved compendium, DrugDex. Therefore, the drug is being prescribed for a medically accepted indication. However, 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: At-Risk Determination
Decision: Favorable

At issue is coverage for Aripiprazole 5 gram tablet to treat delirium due to known physiologic condition and dementia. 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 supports that all of the plans requirements for coverage have been satisfied. Specifically, the patient has significantly improved severe depression and aggression related to dementia with this treatment, and behavior is calm currently. Therefore, the plans prior authorization requirements have been met, and coverage for the drug is supported. 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 coverage for Cyclobenzaprine Hydrochloride 10 milligram tablet to treat muscle spasms due to a chronic musculoskeletal condition. 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 coverage for Retin A 0.6 percent gel pump to treat the enrollee's condition. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. 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 deemed contraindicated. However, the prescriber did not respond to our request. 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 coverage for Lidocaine 5 percent patch to treat low back pain. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.During this review, we requested a prescriber statement and medical records from the prescriber to clarify the condition being treated and to address the plans prior authorization requirements for coverage of this drug. The prescriber did not respond to the request.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 coverage for Tramadol Hydrochloride 50 milligram tablet. 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 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 submitted documentation does not include medical records or evidence of a prescribed diagnosis. During this review, a request was submitted to the prescriber to provide the diagnosis and supporting medical records and to address the plans coverage requirements for this drug. The prescriber did not respond to the request. Without a diagnosis, it cannot be established that the drug has been 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: Unfavorable

At issue is reimbursement for Oxycodone/Acetaminophen 5 milligram tablet prescribed for the enrollee's condition. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all 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. The documentation does not support an extreme emergency that would require the drug be immediately supplied and the drug could have been received from a network pharmacy. Therefore, we determined that the plan is not required to provide reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Loteprednol Etabonate. 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 drug at a network pharmacy. 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 enrollee provided a receipt indicating full payment was made for the drug. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Memantine 50 milligram tablet to treat the enrollee's condition. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The submitted documentation shows the enrollee's pharmacy incorrectly billed the requested drug on July 19, 2023, as 60 tablets for 60 days. The prescribed amount is 60 tablets for 30 days. The request for refill for date of service August 25, 2023, was rejected as refilled to soon. The plan provided documentation showing the enrollee's pharmacy will issue reimbursement for the requested drug for date of service August 25, 2023. Per Chapter 14 of the Medicare Prescription Drug Benefit Manual, retroactive claims adjustments can be necessitated and may be addressed through pharmacy-initiated reverse and rebill transactions. Therefore, we determined that the plan is not required to reimburse the enrollee for their share of the cost for the requested drug, Claims for multiple and/or identical services provided to an individual patient on the same day, may be denied as duplicate claims.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Neosporin topical ointment packet to treat acute lymphangitis of right finger. 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 reviewed all available documentation.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.This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Cefdinir 300 milligram capsule to treat acute upper respiratory infection. 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 reviewed all available documentation.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.This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Bromfenac 0.075 percent compound. 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 drug at a network pharmacy. 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 enrollee provided a statement from the pharmacy indicating full payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Moxifloxacin 0.5 percent compound. 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 drug at a network pharmacy. 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 enrollee provided a statement from the pharmacy indicating full payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Prednisolone 1 percent compound. 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 drug at a network pharmacy. 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 enrollee provided a statement from the pharmacy indicating full payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oral Glucose. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee purchased drugs from a pharmacy on a cruise ship. Drugs purchased on a cruise ship are considered foreign claims outside of the United States and are excluded from coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Diptheria Tetanus Toxoid vaccine. The Part D plan denied the request.We received a case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan's Evidence of Coverage states, if an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The submitted documentation does not include a valid proof of purchase for the drug at issue. Therefore, the request for reimbursement cannot be granted.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tetanus injection prescribed for vaccination. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the vaccine at the prescriber's office. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or prescribers office. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement from the prescribers office and a proof of payment indicating full payment was made for the vaccine and administration fee. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bio Spray 30 milliliter inhalation. 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 Medrol 16 milligram tablets. 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 Molnupiravir 400 milligram capsules. 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 Rhinex 0.05 percent. 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.