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

At issue is reimbursement for an unknown vaccine. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The documentation submitted includes a billing summary from the Summit Medical Group, PA and a Medicare Medical Claim Reimbursement Form.The submitted documentation shows the enrollee received a vaccination at their physicians office. In order to be reimbursed for services paid the information needed to consider the request must include a proof of payment in the form of a receipt, the name of the vaccine/drug, a diagnosis, the drug dosage and drug quantity, and the National Drug Code (NDC) number of the vaccine for verification with the Food and Drug Administration (FDA).
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Tetanus vaccine and administration fee. 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: Unfavorable

At issue is Dorixina-Flam. 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 Kamillosan Mouth wash. 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 Pedialyte. 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 Rhynofar. 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 Throat Spray. 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 Entyvio. 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 coverage for Eylea 2 milligram per 0.5 milliliter vial 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 the enrollee has satisfied the plans prior authorization coverage criteria. 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 submitted documentation does not include medical records or evidence of a prescribed diagnosis. As such, there is insufficient documentation available to establish that the requested 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 Atorvastatin Calcium prescribed for unknown diagnosis. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill. Therefore, we determined the enrollee is responsible for the additional copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bupropion Hydrochloride prescribed for unknown diagnosis. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill. Therefore, we determined the enrollee is responsible for the additional copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Citalopram Hydrobromide prescribed for unknown diagnosis. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill. Therefore, we determined the enrollee is responsible for the additional copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium prescribed for unknown diagnosis. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill. Therefore, we determined the enrollee is responsible for the additional copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dicyclomine Hydrochloride prescribed for unknown diagnosis. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill. Therefore, we determined the enrollee is responsible for the additional copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Farxiga prescribed for unknown diagnosis. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill. Therefore, we determined the enrollee is responsible for the additional copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gabapentin prescribed for unknown diagnosis. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill. Therefore, we determined the enrollee is responsible for the additional copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Glipizide prescribed for unknown diagnosis. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill. Therefore, we determined the enrollee is responsible for the additional copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxyzine Hydrochloride prescribed for unknown diagnosis. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill. Therefore, we determined the enrollee is responsible for the additional copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lantus Solostar prescribed for unknown diagnosis. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill. Therefore, we determined the enrollee is responsible for the additional copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methocarbamol prescribed for unknown diagnosis. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill. Therefore, we determined the enrollee is responsible for the additional copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metoprolol Succinate prescribed for unknown diagnosis. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill. Therefore, we determined the enrollee is responsible for the additional copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spironolactone prescribed for unknown diagnosis. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill. Therefore, we determined the enrollee is responsible for the additional copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sure Comfort Pen Needles prescribed for unknown diagnosis. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill. Therefore, we determined the enrollee is responsible for the additional copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trazodone Hydrochloride prescribed for unknown diagnosis. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill. Therefore, we determined the enrollee is responsible for the additional copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ventolin HFA prescribed for unknown diagnosis. 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 plan reprocessed the enrollees claim for the requested drug and adjusted the amount owed due to a change in the enrollees low income subsidy copayment level. Medicare records indicate the enrollee did not not qualify for low income subsidy copay level for this date of fill. Therefore, we determined the enrollee is responsible for the additional copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rosuvastatin 20 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We determined that the plan is not required to cover the Rosuvastatin. The National Drug Code of the requested drug is not listed with the Food and Drug Administration. Therefore, the drug is excluded from coverage under Medicare Part D. This decision does not concern 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

At issue is coverage for Rybelsus 7 milligram tablet to treat type 2 diabetes. 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 Lynparza 150 milligram tablet to treat glioblastoma. 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 prescriber has submitted a journal article in support of the drug for the enrollee's diagnosis. The Medicare approved journal Clinical Cancer Research contains an article titled 'Resotration of Temozolomide Sensitivity by PARP Inhibitors in Mismatch Repair Deficient Glioblastoma is Independent of Base Excision Repair.' The journal indicates the drug at issue can be used in combination with Temodar for the enrollee's diagnosis. Therefore, the requested drug is being prescribed to treat a medically accepted indication.The plan has prior authorization requirements that must be met before coverage of this drug is provided. However, the plans prior authorization requirements are diagnosis-specific and not related to the condition being treated. Since the condition being treated is a medically accepted indication outlined in the Medicare accepted journal, an exception to the plans diagnosis-specific coverage requirements 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 reimbursement for Cefuroxime Axetil 500 milligram tablet prescribed for the enrollees 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 information 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: Unfavorable

At issue is a tiering exception request for Tiadylt 240 milligram extended release capsule to treat tachycardia, unspecified. 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.Tiadylt is a generic drug on Tier 2 of the plans formulary. There are no generic drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.