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

Medicare rules require a Part D Plan to issue a decision regarding coverage wi thin the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Prolia. The Plan did not grant this request. We received this case to conduct anindependent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Prolia.Prolia is requested to treat osteoporosis. There was insufficient documentation to substantiate that therequested drug is being used to treat the stated condition. The prescriber was asked questions to clarify thediagnosis being treated and/or to provide documentation to support the noted diagnosis. The prescriber wasalso asked questions to address the Plan's Prior Authorization coverage/exception criteria. A response fromthe prescriber was not received. Therefore, based on the current record, there is insufficient documentationto support an exception to the Plan's coverage criteria.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Prolia for the diagnosed condition. As a result, the drug is notbeing prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot becovered under the Medicare Part D benefit for this condition. An exceptions request based on medicalnecessity cannot be considered because this drug, as prescribed, does not meet the definition of a MedicarePart D drug. Therefore, our decision is that the Plan is not required to provide coverage for Prolia.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Opium Tincture. The Plan did not grant this request. We received this case to conduct an independent review.Medicare Part D does not cover drugs that are not FDA approved for both safety and effectiveness. We determined that Opium Tincture is not FDA approved for both safety and effectiveness by checking FDA sources. Therefore, the Plan is not required to cover Opium Tincture. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Testosterone 30 mg/act Solution. The Plan did not grant this request. We received this case to conduct an independent review.Medicare law and Plan rules do not allow tiering exceptions for non-formulary drugs being covered through a formulary exception. The documentation in the record shows that Testosterone 30 mg/act Solution is currently being covered for you through a formulary exception. Therefore, our decision is the Plan is not required to provide a tiering exception for Testosterone 30 mg/act Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Tadalafil. The Plan did not grant this request. We received this case to conductan independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Tadalafil. The drug is requested to treat benign prostatic hyperplasia (BPH). The prescriber has notindicated why all alternatives required by the Plan would likely not be as effective for you as the requesteddrug; and/or would likely cause adverse reaction(s) or other harm to you. Therefore, an exception to thePlan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exceptioncriteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requesteddrug is medically necessary, consistent with the prescriber's statement. Based on a review of the availabledocumentation, our Physician Reviewer's opinion is that formulary exception criteria are not met.Therefore, the Plan is not required to cover Tadalafil.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover and provide reimbursement for Ophthalmic Compounded Solution consistedof Benzalkonium Chloride, Latanoprost, Brimonidine Tartrate, Sodium Chloride, Sodium Hydroxide,Timolol Maleate, Dorzolamide HCL (Sterile Water and Propylene Glycol) purchased March 23, 2020 atthe compound pharmacy. The Plan did not grant this request. We received this case to conduct anindependent review.Medicare Part D does not cover drugs that are not FDA approved. A representative of the pharmacy statedthat bulk powder was used or would be used when compounding the prescription for OphthalmicCompounded Solution consisted of Benzalkonium Chloride, Latanoprost, Brimonidine Tartrate, SodiumChloride, Sodium Hydroxide, Timolol Maleate, Dorzolamide HCL (Sterile Water and Propylene Glycol)purchased March 23, 2020 at the compounding pharmacy. Bulk powders used in pharmacy compoundingare not reviewed and approved for safety and efficacy by the FDA. Therefore, the Plan is not required tocover or provide reimbursement for Ophthalmic Compounded Solution consisted of BenzalkoniumChloride, Latanoprost, Brimonidine Tartrate, Sodium Chloride, Sodium Hydroxide, Timolol Maleate,Dorzolamide HCL (Sterile Water and Propylene Glycol) purchased March 23, 2020 at the compoundingpharmacy.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Shingrix purchased on March 19, 2019, from the pharmacy. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. 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 Plan required a $37 copayment for up to a 30-day supply of a Tier 3 drug purchased from a preferred retail pharmacy in 2019. A request for reimbursement was submitted to the Plan. In this case, the Plan provided documentation showing that this claim was covered by the Plan at the time of purchase. The record shows that Shingrix was purchased for an amount that is less than or equal to the required copayment amount. The case record indicates that the Plan provided coverage in accordance with the Part D contract. Therefore, our decision is the Plan is not required to provide reimbursement for Shingrix purchased on March 19, 2019, from the pharmacy.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for the Lorazepam-Haloperidol-Diphenhydramine Compound purchased May 1, 2020. The Plan did not grant this request. We received this case to conduct an independent review.Medicare Part D does not cover drugs that are not FDA approved. A representative of the pharmacy stated that bulk powder was used when compounding the prescription for the Lorazepam-Haloperidol-Diphenhydramine Compound purchased May 1, 2020. Bulk powders used in pharmacy compounding are not reviewed and approved for safety and efficacy by the FDA. Therefore, the Plan is not required to cover or provide reimbursement for the Lorazepam-Haloperidol-Diphenhydramine Compound purchased May 1, 2020. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for V-Go 40. The Plan did not grant this request. Wereceived this case to conduct an independent review.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug in alower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug isbeing used to treat. In this case, the Plan covers insulin delivery devices as a Tier 3 item only. There are nolower cost-sharing tier insulin delivery devices available on the Plan's formulary. Because there are nolower cost-sharing tier insulin delivery devices, V-Go 40 is not eligible for a tiering exception. Therefore,our decision is the Plan is not required to provide a tiering exception for V-Go 40.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for the Phenylephrine-Lidocaine-Triamcinolone Compound purchased March 17, 2020 and the Diltiazem Compound purchased March 21, 2020. The Plan did not grant this request. We received this case to conduct an independent review.Medicare Part D does not cover drugs that are not FDA approved. A representative of the pharmacy stated that bulk powder was used when compounding the prescriptions for the Phenylephrine-Lidocaine-Triamcinolone Compound purchased March 17, 2020 and the Diltiazem Compound purchased March 21, 2020. Bulk powders used in pharmacy compounding are not reviewed and approved for safety and efficacy by the FDA. Therefore, the Plan is not required to cover provide reimbursement for the Phenylephrine-Lidocaine-Triamcinolone Compound purchased March 17, 2020 and the Diltiazem Compound purchased March 21, 2020. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover and provide reimbursement for Naproxen, Ketorolac Tromethamine, andColchicine purchased on January 17, 2020, while aboard a cruise ship. The Plan did not grant this request.We received this case to conduct an independent review.Naproxen, Ketorolac Tromethamine, and Colchicine are not covered by Medicare because they werepurchased outside the United States. Therefore, our decision is that the Part D Plan is not required to payfor Naproxen, Ketorolac Tromethamine, and Colchicine.This decision does not concern the medical appropriateness of the requested drugs. It only establishes ifpayment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Cranberry Supplement purchased May 10, 2020. The Plan did not grant this request. We received this case to conduct an independent review.Medicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drug's classification or determined from other available resources that the drug is a non-prescription or OTC drug. Therefore, Cranberry Supplement purchased May 10, 2020 is not eligible for Part D coverage, and the Plan is not required to cover or provide reimbursement for it under the Part D benefit. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Sevelamer HCL. The Plan did not grant this request. We received this case toconduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Sevelamer HCL. The drug is requested to treat hyperphosphatemia. Additional medical information wasrequested by the Part D QIC. You were asked to address the formulary alternatives. A response from youwas not received. You have not indicated why all alternatives required by the Plan would likely not be aseffective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harmto the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our PhysicianReviewer's opinion is that formulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requesteddrug is medically necessary, consistent with the prescriber's statement. Based on a review of the availabledocumentation, our Physician Reviewer's opinion is that formulary exception criteria are not met.Therefore, the Plan is not required to cover Sevelamer HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Myrbetriq ER. The Plan did not grant this request. Wereceived this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor a tiering exception for Myrbetriq ER 50 mg.The drug is requested to treat overactive bladder with urinary urgency and frequency. The drug is on tier 4of the Plan's formulary. There are no available lower tier brand drugs on the Plan's formulary to treat theenrollee's condition. Therefore, the drug is not eligible for a tiering exception. Our Physician Reviewer'sopinion is that tiering exception criteria are not met.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of thesame type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in alower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug isbeing used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met becausethere are no lower cost-sharing tiered drugs of the same type for treating the enrollee's condition.Therefore, our decision is the Plan is not required to provide a tiering exception for Myrbetriq ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for Venlafaxine HCL ER 75 mg tablet purchased January 23,2020. The Plan did not grant this request. We received this case to conduct an independent review.In this case, the records show that when Venlafaxine HCL ER 75 mg tablet was purchased on January 23,2020, the claim straddled both the deductible stage and the initial coverage stage of the Part D benefit. Anenrollee is responsible for the full cost of covered drugs until the deductible amount $435 is satisfied. Theinitial coverage phase requires a 44% coinsurance amount for a preferred retail pharmacy. VenlafaxineHCL ER 75 mg tablet is not on the Plan's 2020 Formulary. The Plan provided documentation verifying thescript was written for tablets (not capsules) and that coverage is being provided for Venlafaxine HCL ER75 mg tablet for the 2020 coverage year. Drugs that are not on the formulary, but the Plan agrees to providecoverage (as a formulary exception) are covered at the Tier 4 copayment/coinsurance level.The Plan documentation shows that there was $435 remaining in the deductible phase of coverage. Thisamount is subtracted from the total cost of the drug. This left a remaining total drug cost owed of $79.42.This remaining balance was subject to the initial coverage stage 44% coinsurance amount. 44% of theremaining balance is $34.94. The total of the two figures owed during each benefit phase (deductible andinitial coverage) is $469.94. The record shows that the enrollee was charged an amount that is less than orequal to the required copayment for each phase the claim was processed in. The cost of Venlafaxine HCLER 75 mg tablet purchased January 23, 2020 was applied to your yearly true out-of-pocket (TrOOP) costs.The case record indicates that the Plan provided coverage in accordance with the Part D Plan contract.Therefore, the Plan is not required to provide additional payment and/or reimbursement for VenlafaxineHCL ER 75 mg tablet purchased January 23, 2020.Please note: your Reconsideration appeal request indicates capsules (a Tier 2 drug) should have beendispensed and not tablets. Therefore, you should have paid the Tier 2 copayment amount. The Plan verifiedthe script was written for tablets and not capsules. If you believe the script was written for tablets in error,you may wish to contact your prescriber and/or the pharmacy. The Plan is not required to provide Tier 2copayment/coinsurance amounts for a Tier 4 product.
Appeal type: Prescription Drug
Decision: Favorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Dorzolamide-Timolol purchased on January 2, 2020, from your pharmacy. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. In this case, you did not yet have your Plan member card for 2020 when you purchased Dorzolamide-Timolol from your pharmacy on January 2, 2020. You paid out of pocket because you were unable to access your Part D benefit. The case record indicates that the Plan did not provide coverage in accordance with the Part D Plan contract. Therefore, our decision is the Plan is required to cover and provide any applicable reimbursement for Dorzolamide-Timolol purchased January2, 2020, from your pharmacy.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Aubagio 14 mg tablet. The Plan did not grant this request. We received thiscase to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Aubagio 14 mg tablet. The drug is requested to treat multiple sclerosis. Upon reconsideration, you havesubmitted a sufficiently strong statement supported by medical records as to why the formulary alternativesare inappropriate for the enrollee. You have indicated why all alternatives required by the Plan would likelynot be as effective as the requested drug for the enrollee, and/or would likely cause adverse reaction(s) orother harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is medically necessary.Our Physician Reviewer's opinion is that formulary exception criteria are met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requesteddrug is medically necessary, consistent with the prescriber's statement. Based on a review of the availabledocumentation, our Physician Reviewer's opinion is that formulary exception criteria are met. Therefore,the Plan is required to cover Aubagio 14 mg tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Minivelle 0.05 mg/24hr patch. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for a tiering exception for Minivelle 0.05 mg/24hr patch. The drug is requested to treat N95.1 Menopausal and female climacteric states. Minivelle 0.05 mg/24hr patch is a brand drug on Tier 3 of the Plan's formulary. There are no available lower tier brand drugs of the same type on the Plan's formulary to treat your condition. Therefore, the drug is not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug is being used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met because there are no lower cost-sharing tiered drugs of the same type for treating your condition. Therefore, our decision is the Plan is not required to provide a tiering exception for Minivelle 0.05 mg/24hr patch.