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

At issue is PNSS 1 liter solution prescribed for COVID 19 viral infection. 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 documentationThe submitted documentation shows the enrollee requested the Part D plan to provide reimbursement for the requested drug. However, there is missing information needed to consider the request. The required information does not includes the National Drug Code (NDC) of the requested drug. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sar-Intima prescribed for COVID 19 viral infection. 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 requested product is considered a device by the Food and Drug Administration (FDA). The Part D plan does not cover devices. Therefore, the product is excluded from coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nirmatrelvir/Ritonavir 150 milligram/100 milligram tablet prescribed for COVID 19 viral infection. 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 documentationThe submitted documentation shows the enrollee requested the Part D plan to provide reimbursement for the requested drug. However, there is missing information needed to consider the request. The required information does not includes the National Drug Code (NDC) of the requested drug. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Pimecrolimus 1 percent cream to treat nonspecific rash. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The plan'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 enrollee submitted proof of payment. However, 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 Prolia Solution from 11/03/2022 for 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 plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tenivac 5/2 LFU injection for an immunization. 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 plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug was not provided. Therefore, we determined that the plan is not required to provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methocarbamol tablet prescribed for an unknown 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 Part D plan to provide reimbursement for the requested drug. However, there is missing information needed to consider the request. The required information includes a pharmacy receipt including the drug at issue, the National Drug Code (NDC) of the requested drug and the prescribing physicians name, address and National Provider Identifier (NPI) number. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Buprenorphine 20 micrograms per hour patch to treat the enrollees condition. The Part D plan approved the request for reimbursement 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. Additionally, we researched Medicare systems.The submitted documentation shows the enrollee purchased the requested drug from a retail pharmacy on January 18, 2023, for $251.31. The plans Evidence of Coverage states that if an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The submitted documentation includes the plans Claims Transaction and reimbursement approval letter for the Buprenorphine 20 micrograms per hour patches for $251.31. Therefore, we have determined that the plan has reimbursed you the correct requested amount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Prolia 60 milligram per milliliter solution to treat osteoporosis. 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.Prolia is a biologic drug on Tier 4 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: Favorable

At issue is coverage for Gemtesa 75 milligram oral tablet to treat nocturia. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plan has a step therapy requirement for this drug that must be met before coverage will be provided. The submitted documentation supports that the plans step therapy requirement has been satisfied. Specifically, the enrollee has tried and failed therapy with Myrbetriq, with side effects of elevated blood pressure. Therefore, the plans step therapy requirement has been met and coverage for the drug is supported.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tyrvaya 0.03 milligram nasal spray. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the drug at issue at a network pharmacy. The plans 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 enrollee provided a receipt indicating full payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Amlodipine Besylate. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the drug at issue at a network pharmacy. The plans 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 enrollee provided a receipt indicating full payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Atorvastatin tablets. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the drug at issue at a network pharmacy. The plans 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 enrollee provided a receipt indicating full payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Clonazepam tablets. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the drug at issue at a network pharmacy. The plans 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 enrollee provided a receipt indicating full payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Esomeprazole capsules. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the drug at issue at a network pharmacy. The plans 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 enrollee provided a receipt indicating full payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Lisinopril tablets. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the drug at issue at a network pharmacy. The plans 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 enrollee provided a receipt indicating full payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Raloxifene Hydrochloride tablets. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the drug at issue at a network pharmacy. The plans 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 enrollee provided a receipt indicating full payment was made for the drug at issue. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Lidocaine 5 percent topical patch to treat other pain due to malaise, unspecified and sacrococcygeal disorders, not elsewhere classified. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The noted conditions are off-label uses for the requested drug. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. Therefore, the drug is being prescribed for non-medically accepted indications. 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 Xifaxan 550 milligram tablet to treat small intestinal bacterial overgrowth. 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 Medicare approved compendium, Drugdex, includes an off-label citation for the use of the requested drug to treat small intestinal bacterial overgrowth (SIBO). 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 Drugdex, 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 a tiering exception request for Stiolto Respimat aerosol solution 2.5/2.5 micrograms per actuation to treat chronic obstructive pulmonary disease. 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. Stiolto Respimat aerosol solution 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: Favorable

At issue is Adacel 5/2/15.5/LF microgram/0.5 suspension for diphtheria, tetanus, and acellular pertussis vaccine and the administration fee for date of service May 25, 2023. The Part D plan denied the request for reimbursement.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The record shows the enrollee received the vaccine on May 25, 2023, at the physicians office. The charge was $80.00 for the vaccine and $15.00 for the administration fee. A copy of both sides of the check, for a total of $95.00 is submitted that supports the prescriber deposited the check for services given. The National Drug Code submitted is for the brand name vaccine, Adacel, and the prescribers National Provider Identifier is submitted. The plans Evidence of Coverage states that payment for vaccines is required up front from the enrollee when provided at an out of network pharmacy or at a provider's office. If an enrollee pays the full cost of a prescription and administration fee, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The plans formulary shows the drug is covered as a Tier 3 drug. Therefore, we determined that the plan is required to reimburse the enrollee for their share of the cost for the Adacel vaccine and administration fee for date of service May 25, 2023.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Jardiance 10 milligram tablet to reduce the risk of cardiovascular death and hospitalization due to heart failure. 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 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 Armour Thyroid 90 milligram tablet to treat the enrollee's condition. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Armour Thyroid has not been found by the Food and Drug Administration (FDA) to be safe and effective, and the drug product labeling has not been approved by the FDA. Drugs that are not FDA-approved do not meet the definition of a Part D drug and are excluded from Part D coverage. Therefore, the requested drug is excluded from Medicare Part D coverage.This decision does not address the medical necessity of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Benzonatate 200 milligram capsule to treat cough. 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. Drugs prescribed for the symptomatic relief of coughs are excluded from the Part D coverage. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Ozempic 0.25 milligram or 0.5 milligram per dose (2 milligram per 3 milliliter) solution pen injector, 3 milliliter per 30 days, to treat obesity, hyperlipidemia and hepatic steatosis. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements. 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 Wegovy 0.25 milligram per 0.5 milliliter solution auto injector to treat the enrollees condition. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.At reconsideration, the diagnoses of obesity, hypertension, episodic tension type headaches, and body mass index of 30.0 to 30.9 have been noted. As such, drugs prescribed to treat obesity and/or to promote weight loss are excluded from the Part D coverage. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Lytgobi 4 milligram oral tablet to treat pancreatic cancer with fibroblast growth factor receptor 2 (FGFR2) gene fusion mutation. 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 Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. The submitted documentation does not include any clinically relevant, peer-reviewed medical literature from a Medicare approved journal to support this appeal. Therefore, the available documentation supports that the requested drug is not being prescribed for a medically accepted indication, as defined by Medicare.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 Phentermine Hydrochloride 37.5 milligram oral capsule to promote weight loss. 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.Drugs prescribed to treat obesity and/or to promote weight loss are excluded from the Part D coverage. Therefore, the requested drug is excluded from Medicare Part D coverage.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.