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

You asked the Plan to cover Genotropin Miniquick. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Genotropin Miniquick. The drug is requested to treat G37.9 Demyelinating disease of central nervous system, unspecified, G72.41 Inclusion body myositis, M62.569 Muscle wasting and atrophy, not elsewhere classified, unspecified lower leg, and G62.9 Polyneuropathy, unspecified.The prescriber was asked to clarify the enrollee's diagnosis, because the underlying etiology of the enrollee's condition was unclear from the case file. Supporting medical records were also requested. The prescriber was also asked to address the Plan's prior authorization criteria. A response from the prescriber was not received. Therefore, based on the current record, there is insufficient documentation that the requested medication is being prescribed for a medically accepted indication as defined by Medicare law. In addition, prior authorization exception criteria are not met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. A Plan must grant an exception to prior approval rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on the available documentation, our Physician Reviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is not required to cover Genotropin Miniquick.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Actemra. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Actemra. Actemra is requested to treat an unknown diagnosis. The prescriber was asked to state the enrollee's diagnosis, because there was no prescriber statement of the enrollee's diagnosis in the case file. The prescriber was also asked to address medical necessity for the requested drug. A response from the prescriber was not received. Therefore, based on the current record, there is insufficient documentation that the requested medication is being prescribed for a medically accepted indication as defined by Medicare law. In addition, an exceptions request based on medical necessity cannot be considered because it cannot be confirmed that the drug meets the definition of a Medicare Part D drug.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer needed additional information from the prescriber to determine whether the enrollee is using Actemra for an FDA-approved use, or a use listed in the Medicare-approved compendia. The requested information was not received. As a result, we could not confirm that the drug is being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit. An exceptions request based on medical necessity cannot be considered because it cannot be confirmed that the drug meets the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Actemra. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Janumet. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules do not require the Part D plan to grant a tiering exception for a brand or biologic drug of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) if the lower tier(s) on the formulary only contain(s) generic alternative drugs. Janumet is a Tier 2 brand drug. The lower cost-sharing tier(s) only contain(s) generic alternative drugs. Therefore, our decision is the Plan is not required to provide a tiering exception for Janumet.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Nuedexta. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Nuedexta. The drug is requested to treat Alzheimer's dementia with behavioral disturbance, which is an off-label (non-FDA approved) use. 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. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Nuedexta for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Nuedexta. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Ferriprox. The Plan did not grant this request. Wereceived this case to conduct an independent review.If a Plan maintains a specialty tier, the Plan may design its exception process so that drugs placed in thespecialty tier are not eligible for a tiering exception. Ferriprox is in the specialty tier. The record indicatesthe Plan has chosen to exclude the specialty tier from the tiering exception process. Therefore, the Plan isnot required to provide a tiering exception for Ferriprox.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Spiriva HandiHaler 18 mcg received January 27, 2017. The Plan did not grant this request. We received this case to conduct an independent review.Medicare law requires that Part D Plans coordinate benefits with SPAPs, other entities providing prescription drug coverage, beneficiaries, and others paying on the beneficiaries' behalf for a period of 3 years from the date on which the prescription for a covered Part D drug was filled. This means that claims for coverage and reimbursement must be submitted to the Plan within 3 years from the date of purchase.In this case, the record shows that the purchase(s) in dispute were made in January 2017. A request for coverage/reimbursement was not submitted to the Plan until May 2020. As a result, the claim was not submitted within the Medicare required timeframe of 3 years or less from the date the drug was filled. Therefore, our decision is that the Plan is not required to provide reimbursement for Spiriva HandiHaler 18 mcg received January 27, 2017.Please note: this decision only addresses Spiriva HandiHaler 18 mcg received January 27, 2017 due to the Plan only forwarding the January 27, 2017 date of service for Spiriva HandiHaler. If you would like to dispute other dates of service for Spiriva HandiHaler you may wish to contact the Plan. There are other drugs that are being reviewed under different appeals. You will receive different letters for each drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Synvisc One. The Plan did not grant this request. We received this case to conduct an independent review.Medicare Part D does not cover devices. Synvisc One has been classified by the FDA as a device, not as a drug. Therefore, our decision is the Part D Plan is not required to cover Synvisc One. This decision does not address the medical necessity or appropriateness of the requested item. It only establishes that payment cannot be made under the Medicare Part D benefit.You may wish to submit this request to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Triumeq 600-50-300 mg purchased January 13, 2017,February 15, 2017, January 17, 2018 and February 20, 2018. The Plan did not grant this request. Wereceived this case to conduct an independent review.January 13, 2017 and February 15, 2017Medicare law requires that Part D Plans coordinate benefits with SPAPs, other entities providingprescription drug coverage, beneficiaries, and others paying on the beneficiaries' behalf for a period of 3years from the date on which the prescription for a covered Part D drug was filled. This means that claimsfor coverage and reimbursement must be submitted to the Plan within 3 years from the date of purchase.In this case, the record shows that the purchase(s) in dispute were made in January and February 2017. Arequest for coverage/reimbursement was not submitted to the Plan until May 2020. As a result, the claimswere not submitted within the Medicare required timeframe of 3 years or less from the date the drug wasfilled. Therefore, our decision is that the Plan is not required to provide reimbursement for Triumeq 600-50-300 mg purchased January 13, 2017 and February 15, 2017.January 17, 2018 and February 20, 2018Medicare rules state that an individual that meets requirements under Medicare's low income subsidy (LIS)rules is entitled to a reduction or elimination in the premium, a reduction or elimination in the annualdeductible, a reduction in cost-sharing for all covered Part D drugs below the out-of-pocket limit, and areduction or elimination in cost-sharing for covered Part D drugs above the out-of-pocket limit. The extentof reduction in these benefits depends on an individual's income and resources. According to enrollmentrecords from CMS, you were determined to be entitled to an LIS, copay level 2, effective January 1, 2018through December 31, 2018. For copay level 2, an enrollee is required to pay a $1.25 and $3.70copayments.In this case, the Plan provided documentation that Triumeq was purchased on January 17, 2018 andFebruary 20, 2018 for $3.70. The record shows that Triumeq was purchased for an amount that is less thanor equal to the required LIS copayment amount for these dates.The case record indicates that the Plan provided coverage in accordance with the Part D Plan contract andwith the LIS benefit to which you were entitled. Therefore, our decision is the Plan is not required toprovide reimbursement for Triumeq was purchased on January 17, 2018 and February 20, 2018.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide applicable reimbursement for Lantus 100 unit/ml sol. The Plan did not grantthis request. We received this case to conduct an independent review.The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances.Information in the case record indicates that the enrollee was an outpatient at the hospital when theyreceived this drug. As such, the enrollee was not in a position to obtain the drugs that had been previouslyfilled at a network pharmacy, nor were they able to obtain prior authorization or off-formulary exceptionreview. Since this was a one-time emergency stay, the Plan should provide an exception to their normalcoverage rules. Therefore, our decision is the Plan is required to process the claim for Lantus received as apatient in the hospital.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Estring. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Estring 2 mg. The drug is requested to treat N95.1 - Menopausal and female climacteric states and vaginal atrophy. The prescriber has not indicated why all alternatives required by the Plan would likely not be as effective for you as the requested drug; and/or would likely cause adverse reaction(s) or other harm to you. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are not met. Therefore, the Plan is not required to cover Estring.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Brovana nebulizer solution. The Plan did not grant this request. We receivedthis case to conduct an independent review.Medicare law specifically excludes coverage for any drug for which payment would be available under PartA or Part B of Medicare for that individual. Medicare Part B may pay for supplies necessary for theeffective use of durable medical equipment, including drugs and biologicals which must be put directly intothe equipment in order to achieve the therapeutic benefit of the durable medical equipment. Medicare PartB local policy states that a small volume nebulizer and related compressor are covered when medicallynecessary to administer Brovana nebulizer solution for the management of obstructive pulmonary disease.In this case, the record shows that Brovana nebulizer solution is administered through a nebulizer in thehome for a diagnosis of Unilateral pulmonary emphysema (MacLeod's syndrome)(ICD-10 J43.0) andCentrilobular emphysema (J43.2). There is no indication that it is not administered through a small volumenebulizer. It appears that this medication is eligible for coverage under Part B rather than Part D. Drugswhich are eligible for coverage under Part B are excluded from Part D coverage by Medicare law.Therefore, it is our decision that the Part D Plan is not required to cover Brovana nebulizer solution.This decision does not concern the medical necessity or appropriateness of the requested drug. It onlyestablishes if payment can be made under the Medicare Part D benefit.You may wish to submit this request to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

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

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Eszopiclone. The Plan did not grant this request. We received this case to conduct an independent review.We asked a Physician Reviewer to determine whether the Plan was correct in denying the request for Eszopiclone which is subject to prior approval. Our Physician Reviewer needed additional information from the prescriber to make this determination. The prescriber was asked to address whether the drugs offered by the Plan for the treatment of your condition would: (1) not be as effective as the requested drug; and/or (2) have adverse effects. The requested information was not received. Based on a review of the available documentation, neither prior authorization criteria nor prior authorization exception criteria are met. We also asked the prescriber to address why it is medically necessary for you to have a greater quantity than that allowed by the Plan. The requested information was not received. Based on a review of the available documentation, our Physician Reviewer's opinion is that an exception to the quantity limit criteria for Eszopiclone is not met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs and by covering a limited quantity of certain drugs. A Plan must grant an exception to prior approval rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on the available documentation, our Physician Reviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is not required to cover Eszopiclone.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Veltassa. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules do not require the Part D plan to grant a tiering exception for a brand or biologic drug of the same type (such as brand or biologic drugs when considering an exception for a brand drug if the lower tier(s) on the formulary only contain(s) generic alternative drugs. Veltassa is a Tier 3 brand drug. The lower cost-sharing tier(s) only contain(s) generic alternative drugs. Therefore, our decision is the Plan is not required to provide a tiering exception for Veltassa.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover or provide reimbursement for Hydrocodone Acetaminophen purchased atWalgreen's Pharmacy on January 3, 2020 and Folic Acid purchased March 30, 2020 at the Pharmacy on January 3, 2020 and Folic Acid purchased March 30, 2020 at the Pharmacy. The Plan did not grant this request. We received this case to conduct an independent review.Hydrocodone Acetaminophen purchased January 3, 2020:In this case, you requested coverage and reimbursement for Hydrocodone Acetaminophen purchased at the Pharmacy on January 3, 2020 that was already covered by a Prescription Discount Program. According to the Prescription Discount Program's terms of use found on their website:This program can be used to obtain savings on prescription drugs that are excluded by your insurance planor are not covered because you have exceeded your insurance plan's maximum limits. In some instances,you might find that the Prescription Discount Card's price is lower than your program's copaymentamount. In addition, if your insurance plan does not offer you a drug card and you are reimbursedafter each transaction, you may be able to use the Prescription Discount Card to lower yourout-of-pocket expenses.When you decided to use the Prescription Discount Program you acknowledged and agreed that the Prescription Discount Program will be treated asthe primary pay or with respect to medications that you have selected to purchase through the Prescription Discount Program. Thus, Hydrocodone Acetaminophen purchased Walgreen's Pharmacy on January 3, 2020 at the Pharmacy is not eligible for coverage or reimbursement by Part D. Therefore, it is our decision that thePlan is not required to cover or provide reimbursement for Hydrocodone Acetaminophen purchased at the Pharmacy on January 3, 2020.Folic Acid purchased March 30, 2020:Medicare law excludes certain drugs from Part D coverage. Folic Acid purchased March 30, 2020 at the Pharmacy is one of those excluded drugs because it is a prescription vitamin and mineral product. The record submitted by the Plan does not indicate that they provide supplemental coverage for Folic Acid. Therefore, the Plan is not required to cover or provide reimbursement for Folic Acid purchased March 30, 2020 at the Pharmacy. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.