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

At issue is reimbursement for Terbinafine 250 milligram tablets with a quantity of 75 tablets purchased on September 15, 2023. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows the enrollee received a 15 day supply of Terbinafine 250 milligram tablets on October 31, 2023. The claim was processed and paid which supports a fill should not have been processed after September 8, 2023. A fill of Terbinafine with quantity of 75 tablets was purchased by the enrollee on September 15, 2023. A request for reimbursement for this purchase on September 15, 2023, was received. According to the plans Evidence of Coverage, limits and restrictions are placed on drugs that are refilled too soon. Therefore, the claim for fill date September 15, 2023, is considered a refill too soon, and the amount charged to the enrollee was an out-of-pocket expense. No further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a compound drug consisting of Prednisolone Sodium/Moxifloxacin Hydrochloride/Bromfenac Sodium. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. The plan provided documentation showing the enrollee requested reimbursement for a compounded drug. The compound must have a valid National Drug Codes (NCD) submitted for all of the ingredients. There is not a valid NDC submitted for one of the ingredients. Therefore, we determined the plan is not required to cover or reimburse the enrollee for the compounded drug. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment or reimbursement cannot be made under the Medicare Part D benefit without the required documentation.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Havrix 0.5 milliliter injection prescribed for vaccination. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the vaccine at the prescriber's office. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or prescribers office. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement from the prescribers office and a cancelled check indicating full payment was made for the vaccine and administration fee. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Allopurinol 100 milligram tablet prescribed for unspecified diagnosis. The case was auto forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the requested drug during a hospital stay between 8/21/23-8/23/23. The plans Evidence of Coverage states that if an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The submitted documentation includes a receipt for the requested drug, National Drug Code, and reimbursement request form. Therefore, we determined the plan is required to provide reimbursement for the requested drug based on the enrollee's cost share stage, as the reimbursement criteria are met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Furosemide 20 milligram tablet prescribed for unspecified diagnosis. The case was auto forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the requested drug during a hospital stay between 8/21/23-8/23/23. The plans Evidence of Coverage states that if an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The submitted documentation includes a receipt for the requested drug, National Drug Code, and reimbursement request form. Therefore, we determined the plan is required to provide reimbursement for the requested drug based on the enrollee's cost share stage, as the reimbursement criteria are met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Metoprolol Succinate 50 milligram ER (extended release) tablet prescribed for unspecified diagnosis. The case was auto forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the requested drug during a hospital stay between 8/21/23-8/23/23. The plans Evidence of Coverage states that if an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The submitted documentation includes a receipt for the requested drug, National Drug Code, and reimbursement request form. Therefore, we determined the plan is required to provide reimbursement for the requested drug based on the enrollee's cost share stage, as the reimbursement criteria are met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Prasugrel 10 milligram tablet prescribed for unspecified diagnosis. The case was auto forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the requested drug during a hospital stay between 8/21/23-8/23/23. The plans Evidence of Coverage states that if an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The submitted documentation includes a receipt for the requested drug, National Drug Code, and reimbursement request form. Therefore, we determined the plan is required to provide reimbursement for the requested drug based on the enrollee's cost share stage, as the reimbursement criteria are met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Sacubitril/Valsartan (24 milligram/ 26 milligram) tablet prescribed for unspecified diagnosis. The case was auto forwarded by the plan.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the requested drug during a hospital stay between 8/21/23-8/23/23. The plans Evidence of Coverage states that if an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The submitted documentation includes a receipt for the requested drug, National Drug Code, and reimbursement request form. Therefore, we determined the plan is required to provide reimbursement for the requested drug based on the enrollee's cost share stage, as the reimbursement criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Aspirin to treat an unknown condition on 8/23/2023. The Part D plan denied the request for coverage. The Part D plan auto forwarded the case to us for review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Aspirin is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Levemir 100 units per milliliter FlexPen to treat type 2 diabetes. The Part D plan denied the drug for coverage and then auto-forwarded the case to us for review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not validate that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements have not been met.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Sodium Fluoride 5000 1.1 percent dental paste. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. Sodium Fluoride 5000 is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Rybelsus 7 milligram tablet to treat type ii diabetes mellitus. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements have not been met.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Amphetamine/Dextroamphetamine 10 milligram tablet to treat severe daytime hypersomnolence. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Amlodipine 5 milligram tablet to treat unknown diagnosis. The Part D plan auto forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The submitted documentation shows the enrollee requested the Part D plan to provide reimbursement for the requested drug was given at a facility 11/01/2022-11/04/2022, and 11/20/2022-11/23/2022. However, there is missing information needed to consider the request. The required information includes the National Drug Code (NDC) of the requested drug and the prescribing physicians name, address and National Provider Identifier (NPI) number. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Bupropion 300 milligram tablet to treat unknown diagnosis. The Part D plan auto forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The submitted documentation shows the enrollee requested the Part D plan to provide reimbursement for the requested drug was given at a facility 11/01/2022-11/04/2022, and 11/20/2022-11/23/2022. However, there is missing information needed to consider the request. The required information includes the National Drug Code (NDC) of the requested drug and the prescribing physicians name, address and National Provider Identifier (NPI) number. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Cholecalciferol 25 microgram tablet to treat unknown diagnosis. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. Cholecalciferol is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Doxycycline 100 milligram tablet to treat unknown diagnosis. The Part D plan auto forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The submitted documentation shows the enrollee requested the Part D plan to provide reimbursement for the requested drug was given at a facility 11/01/2022-11/04/2022, and 11/20/2022-11/23/2022. However, there is missing information needed to consider the request. The required information includes the National Drug Code (NDC) of the requested drug and the prescribing physicians name, address and National Provider Identifier (NPI) number. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Guaifenesin 600 milligram tablet to treat unknown diagnosis. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. Guaifenesin is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Loratadine 10 milligram tablet to treat unknown diagnosis. The Part D plan auto forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. Loratadine is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Melatonin 3 milligram tablet to treat unknown diagnosis. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. Melatonin is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Pantoprazole 40 milligram tablet to treat unknown diagnosis. The Part D plan auto forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The submitted documentation shows the enrollee requested the Part D plan to provide reimbursement for the requested drug was given at a facility 11/01/2022-11/04/2022, and 11/20/2022-11/23/2022. However, there is missing information needed to consider the request. The required information includes the National Drug Code (NDC) of the requested drug and the prescribing physicians name, address and National Provider Identifier (NPI) number. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Tolvaptan 15 milligram tablet to treat unknown diagnosis. The Part D plan auto forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The submitted documentation shows the enrollee requested the Part D plan to provide reimbursement for the requested drug was given at a facility 11/01/2022-11/04/2022, and 11/20/2022-11/23/2022. However, there is missing information needed to consider the request. The required information includes the National Drug Code (NDC) of the requested drug and the prescribing physicians name, address and National Provider Identifier (NPI) number. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Eliquis 5 milligram tablet for the prophylaxis of cerebrovascular accident and systemic embolism related to atrial fibrillation. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Avonex 30 microgram prefilled syringe kit to treat the enrollee's condition. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Avonex is included on Tier 5 of the plans formulary. Tier 5 of the formulary is the tier reserved for specialty drugs. The Specialty tier is exempt from tiered cost-sharing expectations, per Medicare rules. Therefore, this drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Ozempic 2 milligram per dose (8 milligram per 3 milliliter) subcutaneous solution to treat type 2 diabetes mellitus. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Ozempic is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Wegovy 0.25 milligram per 0.5 milliliter auto injector to treat obeesity. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Drugs prescribed to treat obesity and/or to promote weight loss are excluded from the Part D coverage. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.