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

At issue is QH Absorb 100 milligram. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Quercetin. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rhodiola 250 milligram. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ther Biotic Factor. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trace Mineral 8 ounce drops. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Turmeric 800 milligram. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zinc Citrate. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is APAP 325 milligram tablet. The Part D plan auto-forwarded 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 purchased the requested drug from an out-of-network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Apixaban 5 milligram tablet. The Part D plan auto-forwarded 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 purchased the requested drug from an out-of-network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buspirone Hydrochloride 5 milligram tablet. The Part D plan auto-forwarded 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 purchased the requested drug from an out-of-network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diltiazem 125 milligram capsule. The Part D plan auto-forwarded 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 purchased the requested drug from an out-of-network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Docusate Sodium 100 milligram capsule. The Part D plan auto-forwarded 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 purchased the requested drug from an out-of-network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Famotidine 20 milligram tablet. The Part D plan auto-forwarded 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 purchased the requested drug from an out-of-network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fludrocort 0.1 milligram tablet. The Part D plan auto-forwarded 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 purchased the requested drug from an out-of-network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluticasone spray. The Part D plan auto-forwarded 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 purchased the requested drug from an out-of-network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Furosemide 20 milligram tablet. The Part D plan auto-forwarded 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 purchased the requested drug from an out-of-network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is KCL 10 milliequivalent capsule. The Part D plan auto-forwarded 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 purchased the requested drug from an out-of-network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lorazepam 0.5 milligram tablet. The Part D plan auto-forwarded 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 purchased the requested drug from an out-of-network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Magnesium. The Part D plan auto-forwarded 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 purchased the requested drug from an out-of-network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metoprolol extended release 50 milligram tablet. The Part D plan auto-forwarded 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 purchased the requested drug from an out-of-network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Phosphorous. The Part D plan auto-forwarded 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 purchased the requested drug from an out-of-network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sacubitril/Valsartan tablet. The Part D plan auto-forwarded 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 purchased the requested drug from an out-of-network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tramadol 50 milligram tablet. The Part D plan auto-forwarded 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 purchased the requested drug from an out-of-network pharmacy in a hospital setting. The documentation lacks evidence to support whether the enrollee's stay was a hospital inpatient or outpatient stay. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. The plan's Evidence of Coverage states, that if the 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. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, without the supporting documentation, the coverage and reimbursement criteria cannot be determined.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bisoprolol 2.5 milligram tablet prescribed for an unspecified diagnosis. The Part D plan auto-forwarded the request.We received a case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The plans 2022 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. The plan submitted documentation that shows the enrollee was in the initial coverage stage when the drug was purchased. The claim for a 100-day supply of the tier 2 drug was approved and a copay of $42.00 was charged to the enrollee at the point of sale. We determined the copay was calculated correctly, based on standard cost sharing for a 100-day supply of a tier 2 drug purchased at a network pharmacy. Therefore, no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Testosterone Cypionate 200 milligram per milliliter solution to treat the enrollees condition. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Testosterone Cypionate 200 milligram per milliliter solution is a generic drug on Tier 3 of the plans formulary. There are no generic drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.