Persius/hicric huggingface dataset:
Appeal type: unknown
Decision: unknown

Citations used in this letter come from Section 42 of the Code of Federal Regulations which you will findabbreviated as 42 CFR with the corresponding section numbers, i.e., 42 CFR Sections 423.578, 423.100.Medicare law defines those drugs that are eligible to be covered under the prescription drug benefit.Medicare law specifically excludes coverage for any drug for which payment would be available underParts A or B of Medicare for that individual. Social Security Act, Section 1860D-2(e)(2)(B).Medicare Part B pays for durable medical equipment (DME) if the equipment is used in the patient's homeor in an institution that is used as a home. Payment may be made for supplies necessary for the effectiveuse of DME. Such supplies include those drugs and biologicals which must be put directly into theequipment in order to achieve the therapeutic benefit of the DME. 42 CFR Section 410.38(a); MedicareBenefit Policy Manual, Chapter 15, Section 110.3.Medicare Part B local policy states that a small volume nebulizer and related compressor are considered forcoverage when medically necessary to administer Tyvaso for the management of pulmonary arterialhypertension (Refer to Group 11 Codes in the LCD-related Policy Article for applicable diagnoses); and2. The pulmonary hypertension is not secondary to pulmonary venous hypertension (e.g., left sided atrial orventricular disease, left sided valvular heart disease, etc.) or disorders of the respiratory system (e.g.,chronic obstructive pulmonary disease, interstitial lung disease, obstructive sleep apnea or other sleepdisordered breathing, alveolar hypoventilation disorders, etc.); and3. The beneficiary has primary pulmonary hypertension or pulmonary hypertension which is secondary toone of the following conditions: connective tissue disease, thromboembolic disease of the pulmonaryarteries, human immunodeficiency virus (HIV) infection, cirrhosis, anorexigens or congenital left to rightshunts. If these conditions are present, the following criteria (a-d) must be met:a. The pulmonary hypertension has progressed despite maximal medical and/or surgical treatment of theidentified condition; andb. The mean pulmonary artery pressure is > 25 mm Hg at rest or > 30 mm Hg with exertion; andc. The beneficiary has significant symptoms from the pulmonary hypertension (i.e., severe dyspnea onexertion, and either fatigability, angina, or syncope); andd. Treatment with oral calcium channel blocking agents has been tried and failed, or has been consideredand ruled out. You can find this rule at Noridian Healthcare Solutions, LLC, Local Coverage Determination(LCD) for Nebulizers (L33370) or CGS Administrators, LLC, Local Coverage Determination (LCD) forNebulizers (L33370) and Local Coverage Article (LCA) for Nebulizers (A52466).The Part D Plan contract states that the Plan cannot cover drugs that would be covered under Medicare PartA or Part B. Please refer to the Plan's Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

Citations used in this letter come from Section 42 of the Code of Federal Regulations which you will find abbreviated as 42 CFR with the corresponding section numbers, i.e., 42 CFR Sections 423.578, 423.100.The prescription drug benefit offered by the Part D Plan must meet certain requirements pertaining to the annual deductible, the initial coverage limit, the coverage gap and catastrophic coverage. For the initial coverage limit, the rules provide for a benefit of shared coverage of costs between the enrollee and plan. An enrollee in a Part D Plan may be subject to annual deductibles, coinsurance, and copayments (including tiered copayments) specified by the plan. 42 CFR Section 423.104.The deductible stage is the first payment stage of the enrollee's drug coverage. During the deductible stage, the Plan requires that the enrollee pays the full cost of drugs before the Plan will pay a share of the cost. Once the enrollee has met the deductible amount of $405 (2018 coverage year) or $435 (2020 coverage year), the enrollee moves into the initial coverage stage. 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. Please refer to the Plan's Evidence of Coverage (EOC) and formulary.
Appeal type: unknown
Decision: unknown

Citations used in this letter come from Section 42 of the Code of Federal Regulations which you will find abbreviated as 42 CFR with the corresponding section numbers, i.e., 42 CFR Sections 423.578, 423.100.Medicare law defines those drugs that are eligible to be covered under the prescription drug benefit. Medicare law specifically excludes coverage for any drug for which payment would be available under Parts A or B of Medicare for that individual. Social Security Act, Section 1860D-2(e)(2)(B). Medicare Part B pays for durable medical equipment (DME) if the equipment is used in the patient's home or in an institution that is used as a home. Payment may be made for supplies necessary for the effective use of DME. Such supplies include those drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the DME. 42 CFR Section 410.38(a); Medicare Benefit Policy Manual, Chapter 15, Section 110.3. Medicare Part B local policy states that a small volume nebulizer and related compressor are considered for coverage when medically necessary to administer acetylcysteine for persistent thick or tenacious pulmonary secretions (refer to the Group 7Codes in the LCD-related Policy Article for applicable diagnoses). You can find this rule at Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) for Nebulizers (L33370) or CGS Administrators, LLC, Local Coverage Determination (LCD) for Nebulizers (L33370) and Local Coverage Article (LCA) for Nebulizers (A52466).The Part D Plan contract states that the Plan cannot cover drugs that would be covered under Medicare Part A or Part B. Please refer to the Plan's Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

Citations used in this letter come from Section 42 of the Code of Federal Regulations which you will findabbreviated as 42 CFR with the corresponding section numbers, i.e., 42 CFR Sections 423.578, 423.100.Medicare rules set forth the requirements and limitations for payments by and on behalf of low-incomeMedicare beneficiaries who enroll in a Part D Plan. In general, an individual that meets requirements underMedicare's low income subsidy (LIS) rules is entitled to a reduction or elimination in the premium, areduction or elimination in the annual deductible, a reduction in cost-sharing for all covered Part D drugsbelow the out-of-pocket limit, and a reduction or elimination in cost-sharing for covered Part D drugsabove the out-of-pocket limit. The extent of reduction in these benefits depends on an individual's incomeand resources. Determinations of eligibility for subsidies are made either by the State (if the individualapplies with the Medicaid agency) or by the Social Security Administration (if the individual applies withthat agency). 42 CFR ?423.771 to 42 CFR ?423.782.According to enrollment records from the Centers for Medicare & Medicaid Services (CMS), you weredetermined to be entitled to a low-income subsidy (LIS), copay level 1, effective January 1, 2020 topresent. For copay level 1, an enrollee is required to pay $3.60 and $8.95 with no deductible.An enrollee in a Part D plan may be subject to annual deductibles, coinsurance, and copayments (includingtiered copayments) specified by the plan. 42 CFR ?423.104.The Part D Plan contract states that Medicare provides extra help to pay prescription drug costs forpeople who have limited income and resources. If you qualify you will get help paying for any Medicaredrug Plan's prescription copayments. Please refer to the Plan's Evidence of Coverage.
Appeal type: unknown
Decision: unknown

Citations used in this letter come from Section 42 of the Code of Federal Regulations which you will findabbreviated as 42 CFR with the corresponding section numbers, i.e., 42 CFR Sections 423.578, 423.100.A Part D plan must have enough contracted retail pharmacies in its network to ensure that enrollees haveadequate access to covered prescription drugs. Access to covered drugs from an out-of-network pharmacyis required when enrollees: (1) cannot reasonably be expected to obtain such drugs at a network pharmacyand (2) do not access covered drugs at out-of-network pharmacies on a routine basis. A plan is required toestablish reasonable rules to appropriately limit out-of-network access to covered prescription drugs. 42CFR Sections 423.120(a) and 423.124; Medicare Prescription Drug Benefit Manual, Chapter 5, Section60.1.An enrollee in a Part D plan may be subject to annual deductibles, coinsurance, and copayments (includingtiered copayments) specified by the plan. 42 CFR Section 423.104.Medicare law defines those drugs that are eligible to be covered under the prescription drug benefit.Medicare law specifically excludes coverage for any drug for which payment would be available underParts A or B of Medicare for that individual. Social Security Act, Section 1860D-2(e)(2)(B).Medicare Part B pays for durable medical equipment (DME) if the equipment is used in the patient's homeor in an institution that is used as a home. Payment may be made for supplies necessary for the effectiveuse of DME. Such supplies include those drugs and biologicals which must be put directly into theequipment in order to achieve the therapeutic benefit of the DME. 42 CFR Section 410.38(a); MedicareBenefit Policy Manual, Chapter 15, Section 110.3.Medicare Part B local policy states that a small volume nebulizer and related compressor are considered forcoverage when medically necessary to administer albuterol, arformoterol (Brovana), budesonide, cromolyn,formoterol, ipratropium, levalbuterol, metaproterenol or revefenacin for the management of obstructivepulmonary disease (Refer to Group 8 Codes in the LCD-related Policy Article for applicable diagnoses).You can find this rule at Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) forNebulizers (L33370) or CGS Administrators, LLC, Local Coverage Determination (LCD) for Nebulizers(L33370) and Local Coverage Article (LCA) for Nebulizers (A52466).The Plan will generally cover prescriptions only if they are filled at a Plan network pharmacy. Prescriptionsfilled at an out-of-network pharmacy may only be covered when a network pharmacy is not available. ThePlan will typically cover prescriptions filled at an out-of-network pharmacy when the prescription is for amedical emergency or urgent care, when there are no 24-hour network pharmacies within a reasonabledriving distance or when the prescription is for a drug that is out of stock at an accessible networkpharmacy. The Part D Plan contract states that the Plan cannot cover drugs that would be covered underMedicare Part A or Part B. Please refer to the Plan's Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

Coverage is available under Medicare Part B for prescription drugs used in immunosuppressive therapy furnished to a beneficiary who has received an organ transplant, provided the beneficiary receiving the drug was enrolled in Medicare Part A at the time of the organ transplant and the transplant was paid for by Medicare. 42 CFR Section 410.30; Medicare Benefit Policy Manual, Chapter 15, Section 50.5.1.The Part D Plan contract states that the Plan cannot cover drugs that would be covered under Medicare Part A or Part B. Please refer to the Plan's Evidence of Coverage (EOC).A Part D plan is permitted to use a number of different tools to manage its formulary. One of these tools is known as prior authorization. This process requires an enrollee to obtain coverage approval for a drug before the drug is dispensed and covered by the plan. 70 Federal Register No. 18, issued January 28, 2005 (Preamble to Final Rule).The Part D Plan can only cover drugs prescribed for a medically accepted indication. The Plan requires prior approval (also called prior authorization) before covering some prescription drugs. If prior approval is not obtained, the Plan may not cover the drug. Please refer to the Plan's Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

Citations used in this letter come from Section 42 of the Code of Federal Regulations which you will find abbreviated as 42 CFR with the corresponding section numbers, i.e., 42 CFR Sections 423.578, 423.100.The prescription drug benefit offered by the Part D Plan must meet certain requirements pertaining to the annual deductible, the initial coverage limit, the coverage gap and catastrophic coverage. For the initial coverage limit, the rules provide for a benefit of shared coverage of costs between the enrollee and plan. An enrollee in a Part D Plan may be subject to annual deductibles, coinsurance, and copayments (including tiered copayments) specified by the plan. 42 CFR Section 423.104.The Part D Plan enrollee may pay part of the cost of a covered drug during the initial coverage period as a copayment or coinsurance. The amount of the copayment or coinsurance will vary depending on the drug's tier and place of purchase. 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 Plan required a $141 for up to a 90 day supply of a Tier 3 drug purchased in 2020 from an in-network pharmacy. Breo Ellipta 200-25 mcg is on the Plan's 2020 formulary and was classified as a Tier 3 drug. Please refer to the Plan's Evidence of Coverage (EOC) and formulary.
Appeal type: unknown
Decision: unknown

Citations used in this letter come from Section 42 of the Code of Federal Regulations which you will find abbreviated as 42 CFR with the corresponding section numbers, i.e., 42 CFR Sections 423.578, 423.100.The prescription drug benefit offered by the Part D Plan must meet certain requirements pertaining to the annual deductible, the initial coverage limit, the coverage gap and catastrophic coverage. For the initial coverage limit, the rules provide for a benefit of shared coverage of costs between the enrollee and plan. An enrollee in a Part D Plan may be subject to annual deductibles, coinsurance, and copayments (including tiered copayments) specified by the plan. 42 CFR Section 423.104.The Part D Plan enrollee may pay part of the cost of a covered drug during the initial coverage period as a copayment or coinsurance. The amount of the copayment or coinsurance will vary depending on the drug's tier and place of purchase. 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 Plan required a 33% coinsurance amount for up to a 30 day supply of a Tier 4 drug purchased in 2020 from a standard retail pharmacy. Drugs that are not on the Plan's formulary that are approved for coverage (as a formulary exception) are covered at the Tier 4 copayment/coinsurance level. Please refer to the Plan's Evidence of Coverage (EOC) and formulary.
Appeal type: unknown
Decision: unknown

Citations used in this letter come from Section 42 of the Code of Federal Regulations which you will find abbreviated as 42 CFR with the corresponding section numbers, i.e., 42 CFR Sections 423.578, 423.100.The prescription drug benefit offered by the Part D Plan must meet certain requirements pertaining to the annual deductible, the initial coverage limit, the coverage gap and catastrophic coverage. For the initial coverage limit, the rules provide for a benefit of shared coverage of costs between the enrollee and plan. An enrollee in a Part D Plan may be subject to annual deductibles, coinsurance, and copayments (including tiered copayments) specified by the plan. 42 CFR Section 423.104.The deductible stage is the first payment stage of the enrollee's drug coverage. During the deductible stage, the Plan requires that the enrollee pays the full cost of Tier 3, Tier 4 and Tier 5 drugs before the Plan will pay a share of the cost. Once the enrollee has met the deductible amount of $435.00, the enrollee moves into the initial coverage stage. 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. Morphine Sulfate ER was on the Plan's 2020 formulary and was classified as a Tier 3 drug. Please refer to the Plan's Evidence of Coverage (EOC) and formulary.
Appeal type: unknown
Decision: unknown

Citations used in this letter come from Section 42 of the Code of Federal Regulations which you will findabbreviated as 42 CFR with the corresponding section numbers, i.e., 42 CFR Sections 423.578, 423.100.Medicare Part D does not cover a (1) drug used for anorexia, weight loss or weight gain; (2) drug used topromote fertility; (3) drug used for cosmetic purposes or to promote hair growth; (4) drug used for thesymptomatic relief of coughs and colds; (5) prescription vitamin and mineral product; (6) non-prescriptionor over-the-counter drug; (7) drug subject to manufacturer tying arrangements; and (8) drug used to treatsexual or erectile dysfunction or (9) sexual or erectile dysfunction drug used to treat a condition other thansexual or erectile dysfunction for which the drug has not been approved by the FDA. Social Security Act,Sections 1860D-2(e)(2)(A), 1927(d)(2) and 1927(d)(4)(C).For a drug to be covered under Medicare Part D, it must meet the definition of a Part D drug. The SocialSecurity Act generally defines a Part D drug as a drug product that meets the following requirements:-It requires a prescription for dispensing; and-It is approved by the Food and Drug Administration (FDA) for safety and effectiveness; and-It is prescribed for a medically accepted indication; and-It is not otherwise excluded from coverage under Part D law and rules.See Social Security Act, Sections 1860D-2(e)(1) and 1927(k)(2)(A)(i)-(iii); and Medicare PrescriptionDrug Benefit Manual, Chapter 6, Section 10.1.The definition of a Part D drug includes only those prescription drugs that are approved by the FDA forsafety and effectiveness. For a drug to be approved by the FDA, the manufacturer of the drug must file aNew Drug Application (NDA) or Abbreviated New Drug Application (ANDA) with the FDA's Center forDrug Evaluation and Research (CDER). Medicare Part D does not pay for drugs that are not FDA approvedprescription drugs. See Social Security Act, Sections 1860D-2(e)(1), 1927(k)(2), and 1927(b)(3).The Part D Plan does not cover those drugs excluded from Medicare Part D coverage. In addition, the Plandoes not offer supplemental (additional) coverage for it. If you purchase drugs that are excluded, you mustpay for them yourself. Please refer to the Plan's Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

Citations used in this letter come from Section 42 of the Code of Federal Regulations which you will find abbreviated as 42 CFR with the corresponding section numbers, i.e., 42 CFR Sections 423.578, 423.100.Pharmaceutical manufacturers sponsor a number of Patient Assistance Programs (PAPs) that provide free product (through in kind product donations) to low-income patients with insufficient or no prescription drug coverage. PAPs operate entirely outside the Part D benefit and any assistance a PAP provides to a Part D enrollee for drugs that would have been covered under his/her Part D plan cannot count as an incurred cost that would be applied toward the enrollee's TrOOP balance or total drug spend. In other words, beginning when a beneficiary's assistance under a PAP is effective (and for as long as the beneficiary remains eligible for PAP assistance), a claim for a drug for which a PAP has provided assistance will never be submitted to a beneficiary's Part D plan. Medicare Prescription Drug Benefit Manual, Chapter 14, Appendix E.The Plan contract states that they are required to follow rules set by Medicare to make sure that the enrollee is using all of their coverage in combination when they get covered drugs from the Plan. This is called coordination of benefits because it involves coordinating the drug benefits the enrollee gets from the Plan with any other drug benefits available. Please refer to the Plan's Evidence of Coverage (EOC).
Appeal type: unknown
Decision: unknown

Citations used in this letter come from Section 42 of the Code of Federal Regulations which you will find abbreviated as 42 CFR with the corresponding section numbers, i.e., 42 CFR Sections 423.578, 423.100.A Part D Plan may establish tiered cost-sharing for drugs on its formulary. The Plan groups covered drugs into different cost-sharing levels or tiers. Medicare rules permit an enrollee to request a tiering exception to cover a higher cost-sharing tiered drug at a lower cost-sharing tier level so long as there is a drug on a lower cost-sharing tier that is approved for treating the same condition that the requested higher cost-sharing tiered drug is being used to treat. However, Medicare rules also permit a Plan to design its tiering exception procedures so that a Plan does not have to grant a tiering exception for brand or biologic drugs if the lower cost-sharing tier or tiers only contain generic drugs approved for treating the same condition. 42 CFR Sections 423.4; 423.578(a); 423.578(a)(6); 423.578(c)(3)(ii); Parts C & D Grievances, Organization/Coverage Determinations, and Appeals Guidance Manual, Section 40.5.1. The prescription drug benefit offered by the Part D Plan must meet criteria requirements pertaining to the annual deductible, the initial coverage limit, the coverage gap and catastrophic coverage. For the initial coverage limit, the rules provide for a benefit of shared coverage of costs between the enrollee and Plan. An enrollee in a Part D Plan may be subject to annual deductibles, coinsurance and copayments (including tiered copayments) specified by the Plan. 42 CFR Section 423.104.The Part D Plan contract allows an enrollee to request an exception to the Plan's cost-sharing tier to pay less for a drug. The prescriber must provide medical reasons to support an exception to the Plan's cost-sharing rules. The Plan will pay its share of the cost for covered drugs and the enrollee will pay the other part during the initial coverage stage. The enrollee stays in this stage until drug payments for the year, plus the Plan's payments, total $3,785. Once total drug costs reach this amount, the enrollee enters the coverage gap stage. During the coverage gap stage, the enrollee pays 25% of the price for brand name drugs (plus a portion of the dispensing fee) and 25% of the price for generic drugs. Please refer to the Plan's Evidence of Coverage (EOC).