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

At issue is Methenamine Hippurate 1 gram tablets prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metoprolol 5 milligram injection prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metoprolol Tartrate 12.5 milligram tablets prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Midazolam PF 1 milligram injection prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Montelukast 10 milligram tablets prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron 4 milligram injection prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pantoprazole 40 milligram capsules prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tetracaine 0.5 percent eye drops prescribed for unspecified diagnosis. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee requested the plan to provide reimbursement for the requested drug. However, the plan indicates the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the requested drug. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Methocarbamol 750 milligram tablets. 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 plans 2023 Evidence of Coverage states, reimbursement for drugs is based the total cost of covered drugs, minus the required deductible, copay, or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The claim information shows the cost of the drug was more than the plan approved amount. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Oxycodone/Acetaminophen 5/325 milligram tablets. 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 plans 2023 Evidence of Coverage states, reimbursement for drugs is based the total cost of covered drugs, minus the required deductible, copay, or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The claim information shows the cost of the drug was more than the plan approved amount. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Insulin. 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 coverage for Rybelsus 7 milligram tablets to treat unknown diagnosis. 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.Rybelsus is a brand drug on Tier 3 of the plans formulary. There are no brand 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Combivent Respimat 20/100 microgram per actuation mist inhaler to treat unknown diagnosis. 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.Combivent Respimat is a brand drug on Tier 3 of the plans formulary. There are no brand 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Methocarbamol 500 milligram tablet to treat unknown diagnosis. 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.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. This information was requested by the Part D plan with no response from the prescriber/prescribers office. 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 Acetaminophen 500 milligram tablets prescribed to treat an unspecified 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. 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 Amoxicillin/Clavulanate Potassium prescribed to treat an unspecified 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. 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 Guaifenisen/Dextromethorphan 200/20 milligram per 10 milliliter syrup prescribed to treat an unspecified 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. 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 Sore Throat 1.4 percent spray prescribed to treat an unspecified 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. 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 Ventolin HFA 90 microgram inhaler prescribed to treat an unspecified 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. 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 coverage for Icosapent Ethyl 1 gram capsule to treat mixed hyperlipidemia. 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 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: Unfavorable

At issue is a tiering exception request for Jardiance 25 milligram tablet to treat diabetes. 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 available documentation.Jardiance 25 milligram tablet is a brand drug on Tier 3 of the plans formulary. There are no brand 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Triazolam 0.25 milligram oral tablet to treat chronic insomnia. 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 Trulicity 0.75 milligram per 0.5 milliliter pen injector to treat 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.Trulicity 0.75 milligram per 0.5 milliliter pen injector is a biologic drug on Tier 3 of the plans formulary. There are no biologic 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Kerendia 10 milligram tablet. The Part D plan denied the request 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.Kerendia is a brand drug on Tier 3 of the plans formulary. There are no brand 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Palonosetron Hydrochloride 0.25 milligram per 5 milliliter vial to treat chemotherapy induced nausea and vomiting. 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 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: Unfavorable

At issue is coverage for a compound drug made using Hydrocortisone 1 percent cream to treat moisture associated skin damage (MASD) and rash and other nonspecific skin eruption. 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 National Drug Code (NDC) number (00168-0015-31) verified with the Food and Drug Administration that the NDC number is not valid. Therefore, the drug is not eligible for coverage under Medicare Part D. We determined the plan is not required to provide reimbursement for the Hydrocortisone 1 percent cream.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.