Persius/hicric huggingface dataset:
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 Dronabinol. The Plan did not grant this request. We received this case to conduct an independent review.Medicare law specifically excludes coverage for any drug for which payment would be available under Parts A or B of Medicare for that individual. Oral anti-emetic drugs are covered under Medicare Part B when they are administered with a particular chemotherapy treatment and initiated within two hours of the administration of the chemotherapeutic agent. They may be continued for a period not to exceed 48 hours from that time. We requested additional medical information to determine if criteria for Part D have been met. We requested the enrollee's diagnosis and ICD-10 code for which Dronabinol has been prescribed, confirmation of whether this drug is used as a full therapeutic replacement for an intravenous anti-emetic drug, and confirmation of whether the requested drug will be given within 48 hours of intravenous chemotherapy. A response to our request was not received in the timeframe required for review of this case. There is insufficient information to show that this drug is not eligible for Medicare Part B coverage. As a result, the record does not establish that Dronabinol is a Part D drug in this case. Therefore, it is our decision that the Part D Plan is not required to provide coverage for Dronabinol. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.You may wish to submit this request to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Prempro. 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 Prempro.Prempro is requested to treat an unknown diagnosis. You were asked to state the enrollee's diagnosis, because there was no prescriber statement of the enrollee's diagnosis in the case file. You were also asked to address medical necessity for the requested drug, to address the Plan's prior authorization criteria, and to provide supporting medical records. A response from you 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 reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Prempro 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 Prempro. 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: Favorable

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 Simvastatin 20 mg. The Plan did not grant this 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. In this case, you were in the hospital. You received several self-administered drugs during this stay. The Plan provided documentation that all Part D eligible self-administered drugs receiving during the stay were approved in a timely manner. However, the Plan did not approve reimbursement for Simvastatin 20 mg tablet due to the National Drug Code (NDC) not being provided. Simvastatin 20 mg tablet is a Part D eligible drug and proof of payment has been verified. Medicare rules state that when a Plan sponsor could acquire missing information, such as the NDC number, by contacting the enrollee's pharmacist, physician, or other prescriber, it should do so instead of relying on the enrollee to provide the information. The Plan may utilize the remainder of the 30-day payment period after approval is granted to obtain missing information in order to determine the amount of reimbursement to be provided. Thus, the Plans reimbursement rules as stated in the Evidence of Coverage have been met, and the Plan should obtain missing NDC information in order to process reimbursement.  The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to provide coverage and reimbursement for Simvastatin 20 mg.  Please note that if the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The health plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will notify you in writing that the case is being reviewed again and the outcome of the reopening.
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 Tacrolimus-Pseudocatalase 0.1% Cream. The Plan did not grant this request. We received this case to conduct an independent review.   Medicare Part D does not cover drugs that are not FDA approved for both safety and effectiveness. We determined that Tacrolimus-Pseudocatalase 0.1% Cream is not FDA approved for both safety and effectiveness by checking FDA sources. Therefore, the Plan is not required to cover or provide reimbursement for Tacrolimus-Pseudocatalase 0.1% Cream.  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.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement (or additional reimbursement) for Novolog, SM Acid Reducer Maximum Strength, Loratadine, Allopurinol, Lantus, Irbesartan, Pantoprazole Sodium, Sertraline HCL, Spironolactone, Torsemide, Amlodipine Besylate, Buspirone HCL, Carvedilol, Ondansetron HCL, Pravastatin Sodium and Trazodone HCL. The Plan did not grant this request. We received this case to conduct an independent review.    SM Acid Reducer Maximum Strength and Loratadine   Medicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drugs' classification or determined from other available resources that the drugs are non-prescription or OTC drugs. Therefore, SM Acid Reducer Maximum Strength and Loratadine are not eligible for Part D coverage, and the Plan is not required to cover or provide reimbursement for them under the Part D benefit.  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.  Allopurinol, Lantus, Irbesartan, Pantoprazole Sodium, Sertraline HCL, Spironolactone, Torsemide, Amlodipine Besylate, Buspirone HCL, Carvedilol, Ondansetron HCL, Pravastatin Sodium and Trazodone HCL  The Part D Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. The Plan submitted documentation showing that they approved coverage. They calculated reimbursement based on the total cost of the drug, less your required copayment amount, and less the difference between what the Plan normally pays for the drug and what the out-of-network pharmacy (i.e., hospital or provider's office) charged you.    The case record indicates that the Plan provided coverage and reimbursement in accordance with the Part D Plan rules for out-of-network reimbursement. Therefore, our decision is the Plan is not required to provide any additional reimbursement for Allopurinol, Lantus, Irbesartan, Pantoprazole Sodium, Sertraline HCL, Spironolactone, Torsemide, Amlodipine Besylate, Buspirone HCL, Carvedilol, Ondansetron HCL, Pravastatin Sodium and Trazodone HCL.  Novolog  The Part D Plan provided documentation that the request for coverage or payment for Novolog while in the hospital was approved as requested. Since the Plan has agreed to provide coverage or payment, there is no need for a reconsideration review.    Contact the Part D Plan to learn more about how and when coverage or payment will be provided for Novolog received while in the hospital.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Lidocaine 5% Patch. 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 Lidocaine 5% patch. The drug is requested for the ongoing treatment of chronic pain/chronic pain in multiple joints, which are off-label (non-FDA approved) uses. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted conditions. Additional medical information was requested by the Part D QIC. You were asked to address the diagnosis and submit medical records to support the diagnosis. The prescriber statement was returned, however, the medical records were not received. 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 conditions.  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 Lidocaine 5% Patch for the diagnosed conditions. 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 these conditions. 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 Lidocaine 5% Patch.  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

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 Budesonide-Formoterol Fumarate HFA. 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 Budesonide-Formoterol Fumarate HFA. Budesonide-Formoterol Fumarate is requested to treat an unknown diagnosis. The prescriber was asked to state your diagnosis, because there was no prescriber statement of your 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, a formulary exception 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 reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Budesonide-Formoterol Fumarate HFA 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 Budesonide-Formoterol Fumarate HFA. 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.Please note: the request for a tiering exception (lower copayment) for Budesonide-Formoterol Fumarate HFA was not reviewed. We cannot consider a tiering exception for a drug for which the Part D Plan is unable to provide coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for Febuxostat 40 mg. The Plan did not grant this request. We received this case to conduct an independent review.In this case, you requested coverage and reimbursement for Febuxostat 40 mg that was already covered by a discount prescription program. According to the discount prescription program terms of use found on their website: This is not insurance. This discount prescription card cannot be used by persons covered by state- or federal-funded programs such as Medicare, Medicaid or Tricare. The card cannot be used with any insurance benefit or copay assistance programs. The card is valid at participating pharmacies only; see the Site or call number below for listing. This discount prescription program is not offering advice, recommending or endorsing any specific drug, pharmacy or other information. Use of this card is subject to additional terms and conditions posted online at the discount prescription program. The discount prescription program does not make payments to providers. When the discount prescription program was used, the discount prescription program was treated as the primary pay or with respect to medications that were purchases through the discount prescription program. Thus, Febuxostat 40 mg is not eligible for coverage or reimbursement by Part D. Therefore, it is our decision that the Plan is not required to cover or provide reimbursement for Febuxostat 40 mg.Please note: your request indicates that you were not aware that the discount prescription program was being used nor did you intend to use it when purchasing Febuxostat. You may wish to contact the pharmacy and ask them to re-run the claims without the Inside Rx discount card and use your Medicare Part D coverage only. Prescription drug costs depend on the pharmacy used and the stage of coverage you are in at the time of purchase. It is noted that removing the discount card may cause an increase in cost for these claims. You may wish to contact the Plan for more information regarding copayment/coinsurance pricing for your Plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Nasonex. 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 Nasonex 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 Nasonex.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Orencia. The Plan did not grant this request. We received this case to conduct an independent review.   Medicare law specifically excludes coverage for any drug for which payment would be available under Parts A or B of Medicare for that individual. Medicare Part B pays for services and supplies incident to the service of a physician (or other practitioner).   In this case, the record reflects that Orencia will be supplied from physician and/or office stock supply, and will be billed as part of a physician service. Orencia is a type of drug that is not usually self-administered. As a result, the drug as administered in this case appears to be eligible for coverage under Medicare Part B. Drugs which 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 Orencia.  This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.  Please contact the Plan for more information regarding coverage of Orencia under the Part B benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Suprep Bowel Prep Kit. 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 tiering exception request for Suprep Bowel Prep Kit. Our Physician Reviewer needed additional information from the prescriber to make this determination. The prescriber was asked to address whether the lower cost-sharing tiered drug(s) offered by the Plan to treat the enrollee's condition would: (1) be less effective than the requested non-preferred drug; and/or (2) have adverse effects. The requested information was not received. Based on a review of the available documentation, our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules require a Plan to grant an exception to its tiering structure whenever it determines that the higher cost-sharing tiered drug for treatment of the enrollee's condition is medically necessary consistent with the prescriber's statement. Our Physician Reviewer's opinion is that tiering exception criteria are not met. Therefore, our decision is the Plan is not required to provide a tiering exception for Suprep Bowel Prep Kit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for Levothyroxine, Aripiprazole and Atomoxetine purchased April 17, 2019 through August 6, 2019. The Plan did not grant this request. We received this case to conduct an independent review.   Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. The amount of the copayment or coinsurance will vary depending on the drug's tier and place of purchase. In this case, you are requesting reimbursement indicating the enrollee paid:  - $9.23 for a 90 day supply of Levothyroxine 75 mcg on April 17, 2019 -  $46.50 for a 90 day supply of Aripiprazole 30 mg and $282.50 for a 90 day supply of Atomoxetine 100 mg on April 19, 2019 -  $11.78 for a 90 day supply of Levothyroxine 75 mg and $282.50 for a 90 day supply of Atomoxetine 100 mg on July 31, 2019 and -  $46.50 for a 90 day supply of Aripiprazole 30 mg on August 6, 2019  However, the pharmacy print out shows the enrollee paid $0 for each of these claims. You did not provide receipts to support that the enrollee paid more than $0 for these claims. Additionally, the Plan provided documentation that each of these claims have been paid by the Plan. the enrollee did not pay anything for these drugs, the Plan is not required to provide any reimbursement.  The case record indicates that the Plan provided coverage in accordance with the Part D Plan contract. Therefore, our decision is the Plan is not required to provide reimbursement for Levothyroxine, Aripiprazole and Atomoxetine purchased April 17, 2019 through August 6, 2019.
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 Humalog, Fluticasone, Hydrochlorothiazide, Lactobacillus Rhamnosus, Metformin, Lisinopril, Simvastatin, Montelukast, Guaifenesin, Aspirin and Azithromycin received February 10, 2020 through February 12, 2020. The Plan did not grant this request. We received this case to conduct an independent review.   The Part D Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. If an enrollee must use an out-of-network pharmacy, the enrollee will generally have to pay the full cost when the prescription is filled. The enrollee may submit a request for reimbursement with proof of payment to ask the Plan to pay its share of the cost.  In this case, the record shows that you were a patient at the hospital from February 10, 2020 through February 12, 2020. You received Humalog, Fluticasone, Hydrochlorothiazide, Lactobacillus Rhamnosus, Metformin, Lisinopril, Simvastatin, Montelukast, Guaifenesin, Aspirin and Azithromycin for a medical emergency or urgent care. You submitted a request for reimbursement. However, the record does not include proof of payment in full of the self-administered drug portion of the bill. Additionally, a representative verified on September 1, 2020 that the self-administered drug portion of the bill has not yet been paid. The Plan's criteria for out-of-network coverage and reimbursement have not been met. Therefore, our decision is the Plan is not required to cover or provide reimbursement for Humalog, Fluticasone, Hydrochlorothiazide, Lactobacillus Rhamnosus, Metformin, Lisinopril, Simvastatin, Montelukast, Guaifenesin, Aspirin and Azithromycin received February 10, 2020 through February 12, 2020.   Please note: once you have paid the remaining balance of the self-administered drug portion of the bill, you may wish to obtain a statement showing a zero balance and submit that to the Plan as proof of payment. Until proof of payment is established, the Plan will not process the claims or provide reimbursement.