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

At issue is Xifaxan 550 milligram tablet to treat diarrhea, unspecified. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

Omnitrope 5 milligram per 1.5 milliliter injection was requested to treat hypopituitarism. The case was auto-forwarded by the planWe received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The documentation submitted indicates the enrolllee has growth hormone deficiency due to a surgical resection of a gonotroph adenoma. There is evidence a insulin-like growth factor 1 level was performed with no current dose adjustments. The documentation satisfies the plans coverage criteria. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

Lidocaine 5 percent patch was requested to treat the enrollees condition. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria and to provide supporting medical records. A reply from the prescriber was not received. Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

Methocarbamol 750 milligram tablet was requested to treat the enrollees condition. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria and to provide supporting medical records. A reply from the prescriber was not received. Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocodone-Acetaminophen 10/325 milligram tablet. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested a diagnosis and medical records with a prescriber statement to support why the quantity prescribed was medically necessary for the enrollee. However, we did not receive the requested information.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a direct member reimbursement request for C-Interstitial Cyctitis 60 milliliter compounded solution. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation supports the plan has issued payment for $37.20 for the compounded medication at issue. The compounded medication at issue is composed of Gentamycin Sulfate bulk powder, Liodcaine Hydrochloride bulk powder, Solu-Cortef, and Heparin Sodium. The plan issued payment for some of the ingredients of the compound and denied the other components. The Gentamycin Sulfate and Lidocaine Hydrochloride do not meet the definition of a Part D drug. These ingredients are derived from bulk powders. Bulk powders do not meet the definition of Part D drugs. Therefore, the compounded drug is not eligible for further reimbursement under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Allopurinol 300 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for the requested drug were approved and copayments were charged correctly to the enrollee at the point of sale for dates of fill April 23, 2021 and July 9, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage when this tier 1 drug was purchased. Therefore, we determined the copay charged was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amoxicillin/Potassium Clavulanate 875/125 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale for date of fill April 7, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage when this tier 2 drug was purchased. Therefore, we determined the copay charged was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amoxicillin/Potassium Clavulanate 875/125 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale for date of fill March 27, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage when this tier 2 drug was purchased. Therefore, we determined the copay charged was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is BD Swab Single Use Regular Pad prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale for date of fill August 4, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage when this tier 2 drug was purchased. Therefore, we determined the copay charged was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is BD Swab Single Use Regular Pad prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for the requested drug were approved and the amount charged for date of fill January 19, 2021 was applied to the enrollee's deductible, and for date of fill April 19, 2021, a copayment was charged correctly to the enrollee at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the deductible cost share stage for date of fill January 19, 2021, and the coverage gap cost share stage for date of fill April 19, 2021 for the tier 2 drug. Therefore, we determined amounts charged to the enrollee were correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Betamethasone Dipropionate 0.05 percent cream prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale for date of fill June 30, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage when this tier 3 drug was purchased. Therefore, we determined the copay charged was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Betamethasone Dipropionate 0.05 percent cream prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for the requested drug were approved and copayments were charged correctly to the enrollee at the point of sale for dates of fill April 16, 2021 and June 30, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage for the requested tier 3 drug on the dates of fill, April 16, 2021 and June 30, 2021. Therefore, we determined the copay amounts were correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buspirone Hydrochloride 15 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale for date of fill June 1, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage when this tier 1 drug was purchased. Therefore, we determined the copay charged was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cephalexin 500 milligram capsule prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale for date of fill June 11, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage when this tier 1 drug was purchased. Therefore, we determined the copay charged was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Duloxetine Hydrochloride 30 milligram delayed release part capsule prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale for date of fill February 3, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the initial coverage cost share stage when this tier 2 drug was purchased. Therefore, we determined the copay charged was correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Duloxetine Hydrochloride 60 milligram delayed release part capsule prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and the charge was applied to the deductible correctly at the point of sale for date of fill January 19, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the deductible cost share stage when this tier 2 drug was purchased. Therefore, we determined the amount was applied to the enrollee's deductible correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Duloxetine Hydrochloride 60 milligram delayed release part capsule prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for the requested drug were approved and copayments were charged correctly to the enrollee at the point of sale for dates of fill March 17, 2021 and June 1, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the initial coverage cost share stage when this tier 2 drug was purchased on March 17, 2021 and in the coverage gap stage on date of fill June 1, 2021. Therefore, we determined the copays charged were correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Easy Touch Insulin syringe prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for the requested drug were approved. The enrollee was in the deductible cost share stage for part of the cost of the drug and crossed into the initial coverage stage for the remaining amount for date of fill January 22, 2021. The enrollee was in the coverage gap cost share stage for date of fill August 4, 2021, and was charged a copay at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required deductible, copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the deductible/initial coverage stages when this tier 2 drug was purchased on January 22, 2021 and in the coverage gap cost share stage on date of fill August 4, 2021. Therefore, we determined the deductible and copays charged were correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estradiol 0.1 milligram/gram cream prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claims for the requested drug were approved and copayments were charged correctly to the enrollee at the point of sale for dates of fill March 22, 2021 and June 12, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap/initial coverage and coverage gap cost share stages when this tier 3 drug was purchased on March 22, 2021 and June 12, 2021. Therefore, we determined the copays charged were correct and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estradiol 10 microgram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged correctly to the enrollee at the point of sale for date of fill March 26, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The enrollee was in the coverage gap cost share stage when this tier 4 drug was purchased. Therefore, we determined the copay charged was correct and no further reimbursement is required by the plan.