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

At issue is coverage for Morphine Sulfate extended release 60 milligram tablet. 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.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that the enrollee has satisfied the plans prior authorization coverage criteria. However, the prescriber did not respond to our request.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 submitted documentation does not include medical records or evidence of a prescribed diagnosis. This information was requested by the Part D plan with no response from the prescriber. As such, there is insufficient documentation available to establish that the requested drug has been prescribed for a 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 Xtandi 40 milligram capsule to treat recurrent prostate cancer, with an unclear diagnosis presented. 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.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the diagnosis, and the enrollee has satisfied the plans prior authorization coverage criteria. There is conflicting information regarding the patient's diagnosis, and no clinical notes corroborate the diagnosis. We received additional documentation and included it in the review.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 Medicare-approved compendia does not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition, which is not supported in the documentation submitted. The submitted documentation does not include clinically relevant, peer-reviewed medical literature from a Medicare-approved journal to support this appeal. Therefore, the available documentation supports that the requested drug is not being prescribed for a medically accepted indication, as Medicare defines.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: At-Risk Determination
Decision: Unfavorable

At issue is Oxycodone 15 milligram tablet prescribed 180 per 30 days. 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 read the 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 plan limits the amount of opioids to 90 morphine milligram equivalent per day. The plan has indicated the enrollees prescription history and the drug at issue will exceed the plans limitation. The submitted documentation supports the enrollee will have 135 morphine milligram equivalent per day on hand. The prescriber has not indicated the medical necessity for exceeding the plans limitation. Therefore, an exception to the plans coverage criteria is not supported. 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 Byetta to treat the enrollees condition. The Part D plan denied the request 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 documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omega 3 Acid Esters to treat the enrollees condition. The Part D plan denied the request 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 documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxybutynin Chloride ER (extended release) to treat the enrollees condition. The Part D plan denied the request 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 documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol inhaler prescribed for an unknown diagnosis. 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 submitted documentation shows the enrollee received Clonidine as a self-administered drug during a Part A hospital stay. According to the plan's Evidence of Coverage, 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. The enrollee provided a hospital Medication Administration Record of the drugs given during the Part A stay. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, the reimbursement criteria have not been met.Please note that the 11 digit National Drug Code (NDC) number for each drug will need to submitted with future correspondence. This number can be obtained from the hospital.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 Amlodipine 10 milligram tablet prescribed for an unknown diagnosis. 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 submitted documentation shows the enrollee received Clonidine as a self-administered drug during a Part A hospital stay. According to the plan's Evidence of Coverage, 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. The enrollee provided a hospital Medication Administration Record of the drugs given during the Part A stay. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, the reimbursement criteria have not been met.Please note that the 11 digit National Drug Code (NDC) number for each drug will need to be submitted with future correspondence. This number can be obtained from the hospital.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 Carvedilol 25 milligram tablet prescribed for an unknown diagnosis. 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 submitted documentation shows the enrollee received Clonidine as a self-administered drug during a Part A hospital stay. According to the plan's Evidence of Coverage, 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. The enrollee provided a hospital Medication Administration Record of the drugs given during the Part A stay. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, the reimbursement criteria have not been met.Please note that the 11 digit National Drug Code (NDC) number for each drug will need to be submitted with future correspondence. This number can be obtained from the hospital.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 Clonidine prescribed for an unknown diagnosis. 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 submitted documentation shows the enrollee received Clonidine as a self-administered drug during a Part A hospital stay. According to the plan's Evidence of Coverage, 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. The enrollee provided a hospital Medication Administration Record of the drugs given during the Part A stay. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, the reimbursement criteria have not been met.Please note that the 11 digit National Drug Code (NDC) number for each separate drug will need to be submitted with future correspondence. This number can be obtained from the hospital.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 Eliquis 2.5 milligram tablet prescribed for an unknown diagnosis. 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 submitted documentation shows the enrollee received Clonidine as a self-administered drug during a Part A hospital stay. According to the plan's Evidence of Coverage, 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. The enrollee provided a hospital Medication Administration Record of the drugs given during the Part A stay. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, the reimbursement criteria have not been met.Please note that the 11 digit National Drug Code (NDC) number for each drug will need to be submitted with future correspondence. This number can be obtained from the hospital.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 Losartan 50 milligram tablet prescribed for an unknown diagnosis. 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 submitted documentation shows the enrollee received Clonidine as a self-administered drug during a Part A hospital stay. According to the plan's Evidence of Coverage, 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. The enrollee provided a hospital Medication Administration Record of the drugs given during the Part A stay. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, the reimbursement criteria have not been met.Please note that the 11 digit National Drug Code (NDC) number for each drug will need to be submitted with future correspondence. This number can be obtained from the hospital.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 Pantoprazole 40 milligram tablet prescribed for an unknown diagnosis. 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 submitted documentation shows the enrollee received Clonidine as a self-administered drug during a Part A hospital stay. According to the plan's Evidence of Coverage, 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. The enrollee provided a hospital Medication Administration Record of the drugs given during the Part A stay. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, the reimbursement criteria have not been met.Please note that the 11 digit National Drug Code (NDC) number for each drug will need to submitted with future correspondence. This number can be obtained from the hospital.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 Pravastatin 20 milligram tablet prescribed for an unknown diagnosis. 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 submitted documentation shows the enrollee received Clonidine as a self-administered drug during a Part A hospital stay. According to the plan's Evidence of Coverage, 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. The enrollee provided a hospital Medication Administration Record of the drugs given during the Part A stay. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, the reimbursement criteria have not been met.Please note that the 11 digit National Drug Code (NDC) number for each drug will need to be submitted with future correspondence. This number can be obtained from the hospital.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 Spiriva Respimat (Stiolto Respimat) prescribed for an unknown diagnosis. 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 submitted documentation shows the enrollee received Clonidine as a self-administered drug during a Part A hospital stay. According to the plan's Evidence of Coverage, 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. The enrollee provided a hospital Medication Administration Record of the drugs given during the Part A stay. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, the reimbursement criteria have not been met.Please note that the 11 digit National Drug Code (NDC) number for each drug will need to be submitted with future correspondence. This number can be obtained from the hospital.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: Favorable

At issue is reimbursement for Engerix-B 20 microgram per milliliter suspension prefilled syringe prescribed for vaccination.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 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 receipt indicating full payment was made for the vaccine and administration fee. Therefore, we determined the criteria have been met for reimbursement.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Rinvoq 15 milligram ER (extended release) tablet to treat moderate to severe active rheumatoid arthritis. 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.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that the enrollee has satisfied the plans prior authorization coverage criteria. We received additional documentation and included it in the review. The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation supports that all of the plans requirements for coverage have been satisfied. Specifically, the prescriber submitted records with documentation that Azathioprine has been discontinued. The patient has had greater than a 3-month trial of conventional therapy and has tried and failed a (TNF) tumor necrosis factor inhibitor. Therefore, the plans prior authorization requirements have been met and coverage for the drug is supported.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine Hydrochloride. 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 requested the plan to provide reimbursement. The plan's Evidence of Coverage states, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, the documentation does not include the National Drug Code (NDC). Therefore, we determined that the plan is not required to reimburse the enrollee without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bupropion Hydrochloride prescribed for an unknown diagnosis. The Part D plan denied/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. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee filled a prescription for the requested drug at a network pharmacy. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Duloxetine Hydrochloride prescribed for an unknown diagnosis. The Part D plan denied/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. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee filled a prescription for the requested drug at a network pharmacy. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Polyethylene Glycol prescribed for an unknown diagnosis. The Part D plan denied/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. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee filled a prescription for the requested drug at a network pharmacy. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug was not provided. Therefore, the reimbursement criteria have not been met.