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 usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Tramamyl 50 mg Gel, Innohep 450oui A-X A/D andSigvaris Diaph2 Bas purchased September 14, 2019 and September 17, 2019 while outside the United States. The Plan did not grant this request. We received this case to conduct an independent review.Tramamyl 50 mg Gel, Innohep 450oui A-X A/D and Sigvaris Diaph2 Bas purchased September 14, 2019and September 17, 2019 while outside the United States are not covered by Medicare because they were purchased outsidethe United States. Therefore, our decision is that the Part D Plan is not required to pay for Tramamyl 50 mgGel, Innohep 450oui A-X A/D and Sigvaris Diaph2 Bas purchased September 14, 2019 and September 17,2019 while outside the United States.This decision does not concern the medical appropriateness of the requested drug. It only establishes ifpayment 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 usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Clamoxin received January 24, 2020 while outside the United States.The Plan did not grant this request. We received this case to conduct an independent review.Clamoxin received January 24, 2020 while in Mexico is not covered by Medicare because it was purchasedoutside the United States. Therefore, our decision is that the Part D Plan is not required to pay for Clamoxinreceived January 24, 2020 while outside the United States.This decision does not concern the medical appropriateness of the requested drug. It only establishes ifpayment 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 usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for the TriMix Compound purchased March 5, 2020. ThePlan 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. A representative of the pharmacy statedthat bulk powder was used when compounding the prescription for the TriMix Compound purchasedMarch 5, 2020. Bulk powders used in pharmacy compounding are not reviewed and approved for safetyand efficacy by the FDA. Therefore, the Plan is not required to cover or provide reimbursement for theTriMix Compound purchased March 5, 2020.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes 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 usas required by Medicare rules because it did not make a timely decision.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 ICD-10 J44.9 (Chronic obstructive pulmonary disease, unspecified). There is noindication that it is not administered through a small volume nebulizer. It appears that this medication iseligible for coverage under Part B rather than Part D. Drugs which are eligible for coverage under Part Bare excluded from Part D coverage by Medicare law. Therefore, it is our decision that the Part D Plan is notrequired 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.Please contact the Plan for more information regarding coverage of Brovana nebulizer solution under thePart B benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Epidiolex. 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 Epidioloex 100 mg/mL. The drug is requested to treat refractory drug-resistant partial epilepsy in the absence of Lennox-Gastaut syndrome or Dravet syndrome, 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 Epidiolex 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 Epidiolex. 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 usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Lidocaine patch. The Plan did not grant this request. We received this case toconduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Lidocaine 5% patch. Lidocaine 5% patch is requested to treat rheumatoid arthritis, low back pain andosteoarthritis. For coverage under the prescription drug benefit, Medicare requires that the drug prescribedbe used for a medically accepted indication. Our Physician Reviewer found that the Medicare-approvedresources do contain citations to support the use of the requested drug for treatment of the noted condition(low back pain). Therefore, the requested drug is being prescribed for a medically accepted indication. Theenrollee does not satisfy the Plan's coverage criteria. The prescriber has not sufficiently addressed the Plan'scoverage criteria and/or has not indicated why all alternatives required by the Plan would likely not be aseffective for the enrollee as the requested drug, and/or would likely cause adverse reaction(s) or other harmto the enrollee. Of note, a request for records was sent to the prescriber as additional diagnoses for therequested drug were added at the reconsideration level (low back pain and osteoarthritis). Despite therequest no supporting medical records to substantiate the prescriber's indicated diagnoses were provided.Our Physician's opinion is that neither prior authorization nor prior authorization exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. APlan must grant an exception to prior approval rules if it determines that the requested drug is medicallynecessary, consistent with the prescriber's statement. Based on the available documentation, our PhysicianReviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is notrequired to cover Lidocaine patch.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Cardizem CD 120mg ER capsules 90 per 90 days. The Plan did not grant thisrequest. 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 requestfor Cardizem CD 120mg ER capsules 90 per 90 days. The drug is requested to treat the enrollee'scondition. There are no applicable utilization management criteria identified for coverage of the drug. Therequested drug is labeled as Non-Extended Days' Supply (NDS) under the formulary. NDS medications arelimited up to a 30-day maximum supply. Our Physician Reviewer found that Medicare resources supportthe use of the requested drug for a 90-day supply exception outside of the NDS medication limit related toCoronavirus/COVID-19.According to the memo from March 10, 2020, the Centers for Medicare & Medicaid Services (CMS)issued guidance notifying Medicare Advantage Organizations (MAOs) and Part D sponsors of a number offlexibilities they may implement during the coronavirus disease 2019 (COVID-19) public healthemergency to support efforts that can help curb the spread of the virus and to help ensure MA and Part Denrollees do not experience disruptions in care or disruptions in pharmacy and prescription drug access.Since issuing this guidance, CMS has continued to receive requests for additional guidance regardingCMS's expectations with respect to other CMS and MAO and Part D sponsor policies and requirementsduring this public health emergency. This memo (revised April 20, 2020) supersedes and replaces theMarch 10, 2020 memorandum.Due to the public health emergency posed by COVID-19 and the urgent need to ensure access to healthcare items and services covered by MA, Part D and Medicare-Medicaid plans, particularly in light ofisolation and social distancing measures that are necessary to contain the spread of COVID-19, CMS isexercising its enforcement discretion to adopt a temporary policy of relaxed enforcement in connectionwith the policies discussed in this memo under the conditions outlined herein.CMS is issuing this information to Medicare Advantage Organizations and Part D Sponsors to inform themof the obligations and permissible flexibilities related to disasters and emergencies resulting from COVID-19.Part D sponsors must permit enrollees to obtain the total days supply prescribed for a covered Part D drug(as defined in 42 CFR 423.100) up to a 90-day supply in one fill (or one refill) if:*Requested by the enrollee,*PA or ST requirements have been satisfied; and*No safety edits otherwise limit the quantity or days supply.Our Physician Reviewer's opinion is that Medicare Part D criteria for coverage for a 90-day supply of therequested drug have been met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior authorization, step therapy orquantity limits. Cardizem CD is on the Plan's formulary and is not subject to any of these restrictions.Therefore, our decision is the Plan is required to cover Cardizem CD.
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 Lidocaine 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 to treat the enrollee's condition. The initial request did not specify the enrollee's condition. Additional medical information was requested by the Part D QIC. The prescribing physician was asked to address the Plan's prior authorization criteria, to provide the enrollee's diagnosis, and to submit medical records supporting the enrollee's diagnosis. The prescribing physician submitted a diagnosis of post-herpetic neuralgia but the requested medical records were not submitted. The enrollee does not satisfy the Plan's coverage criteria. The prescriber has not sufficiently addressed the Plan's coverage criteria and/or has not indicated why all alternatives required by the Plan would likely not be as effective for the enrollee as the requested drug, and/or would likely cause adverse reaction(s) or other harm to the enrollee. Our Physician's opinion is that neither prior authorization nor prior authorization exception criteria are 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 Lidocaine Patch.
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 or provide reimbursement for Oxycodone Acetaminophen purchased from the pharmacy. 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 Oxycodone Acetaminophen that was already covered by Discount prescription card. According to the discount prescription program terms of use found on their website:DISCOUNT ONLY - NOT INSURANCE. Discounts are available exclusively through participating pharmacies. The range of the discounts will vary depending on the type of prescription and the pharmacy chosen. This program does not make payments directly to pharmacies. Members are required to pay for all prescription purchases. Cannot be used in conjunction with insurance. You may contact customer care anytime with questions or concerns, to cancel your registration, or to obtain further information.When you decided to use discount prescription program you acknowledged and agreed that discount prescription program will be treated as the primary pay or with respect to medications that you have selected to purchase through the discount prescription program Services. Thus, Oxycodone Acetaminophen 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 Oxycodone Acetaminophen.
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 the Estradiol Compound purchased February 12, 2020. 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. A representative of the pharmacy stated that bulk powder was used when compounding the prescription for the Estradiol Compound purchased February 12, 2020. Bulk powders used in pharmacy compounding are not reviewed and approved for safety and efficacy by the FDA. Therefore, the Plan is not required to cover provide reimbursement for the Estradiol Compound purchased February 12, 2020. This decision does not address the medical necessity or appropriateness 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 usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Losartan Potassium 50 mg purchased January 25, 2020;Digoxin 0.125 mg purchased January 27, 2020; Ciprofloxacin 500 mg and Tamsulosin 0.4 mg purchasedFebruary 22, 2020; Digoxin 0.125 mg and Simvastatin 10 mg purchased March 6, 2020; and LosartanPotassium 50 mg purchased May 2, 2020. The Plan did not grant this request. We received this case toconduct an independent review.Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. The amount ofthe copayment or coinsurance will vary depending on the drug's tier and place of purchase. In this case, youpurchased Losartan Potassium 50 mg, Digoxin 0.125 mg, Ciprofloxacin 500 mg, Tamsulosin 0.4 mg andSimvastatin 10 mg between January 25, 2020 and May 2, 2020. You requested reimbursement from thePart D Plan. The Plan did not provide any documentation that these claims have been paid at point of saleor have been processed since being purchased. The documentation submitted by the Plan includes proof ofpayment for each of these Part D eligible drugs. The documentation also indicates the pharmacy used wasin-network and the Plan has not provided any reason why the claims should not be processed andapplicable reimbursement provided at this time.The case record indicates that the Plan did not provide coverage in accordance with the Part D Plancontract. Therefore, our decision is the Plan is required to provide reimbursement for Losartan Potassium50 mg purchased January 25, 2020; Digoxin 0.125mg purchased January 27, 2020; Ciprofloxacin 500 mgand Tamsulosin 0.4 mg purchased February 22, 2020; Digoxin 0.125 mg and Simvastatin 10 mg purchasedMarch 6, 2020; and Losartan Potassium 50 mg purchased May 2, 2020.
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 Esomeprazole DR, 20 mg capsule. 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 Plan was correct in denying the request for Esomeprazole, 20 mg.Esomeprazole, 20 mg is requested to treat gastroesophageal reflux disease (GERD) without esophagitis. Additional medical information was requested by the Part D QIC. The prescribing physician was asked to address the enrollee's trial of one generic proton pump inhibitor (Lansoprazole, Omeprazole, Pantoprazole, or Rabeprazole) and provide medical records, drugs tried, dates, and results of drug trials.The prescriber statement was returned. Medical records with confirmation and details of drug trials were not provided. The prescriber indicated that the enrollee has tried one alternative required by the Plan (Omeprazole), however, not why the Plan's required step therapy drugs would likely not be as effective for the enrollee as the requested drug, and/or would likely cause adverse reactions or other harm to the enrollee. Our Physician Reviewer's opinion is that neither step therapy or step therapy exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring step therapy for certain drugs. A Plan must grant an exception 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 an exception to step therapy criteria is not met. Therefore, the Plan is not required to cover Esomeprazole DR, 20 mg capsule.
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 a tiering exception for Dorzolamide-Timolol eye drops. The Plan did notgrant 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 requestfor a tiering exception for Dorzolamide-Timolol 2%/0.5% eye drops. The drug is requested to treatglaucoma. The drug is on Tier 4 of the Plan's formulary. There are no available lower tier drugs on thePlan's formulary to treat the enrollee's condition. Therefore, the drug is not eligible for a tiering exception.Our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of thesame type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in alower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug isbeing used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met becausethere are no lower cost-sharing tiered drugs of the same type for treating the enrollee's condition.Therefore, our decision is the Plan is not required to provide a tiering exception for Dorzolamide-Timololeye drops.