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

At issue is Omeprazole 20 milligram capsule prescribed to treat an unspecified diagnosis. 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 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 Omeprazole as a self-administered drug in the hospital. However, there is missing information needed to consider the request. The required information includes proof of payment in the form of a receipt or physicians or hospital statement showing the amount that was paid by the enrollee, the prescribing physicians name, address and National Provider Identifier (NPI) number, and the National Drug Code (NDC) of the drug. Additionally, according to the plan's Evidence of Coverage, if the enrollee pays the full cost of a drug, 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 statement including the amount charged for the self-administered drug. However, the enrollees proof of payment in the form of a receipt and NDC number were not provided. Therefore, the reimbursement criteria have not been met.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 Linezolid 600 milligram tablet prescribed for enrollee's condition. 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. This request was denied under Medicare Part D because: This drug required a prior authorization, and the prescriber information does not meet the prior authorization criteria of the plan. The plan has denied coverage and payment of the drug. At appeal, the prescriber did not supply the prior authorization required by the plan to cover this drug. In addition, there is a valid paid receipt provided for the drug with the required information but, the prescriber has not submitted a valid 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 Amoxicillin/Clavulanate Potassium 875/125 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the additional reimbursement 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 that the enrollee is requesting reimbursement for the Amoxicillin/Clavulanate Potassium purchased at a net-work pharmacy. 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. In this case, documentation was provided showing the Medicare contracted price for the prescription was allowed by the plan and reimbursement has been made. The plan will only reimburse up to the contracted price of the drug, minus any deductible, copay or coinsurance. Therefore, we determined that the plan calculated reimbursement correctly and is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Inrebic 100 milligram capsules. 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. Medicare records show the enrollee was not enrolled with the Part D plan for the dates of service requested. Therefore, we determined that the plan is not required to provide coverage or reimbursement for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage and reimbursement for Azithromycin 500 milligram tablet to treat the enrollees 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 documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The plan provided claim information for the enrollee indicating the drug at issue was dispensed at a pharmacy not in the plans network on the date the prescription was filled. In these instances, the enrollee may be responsible for paying the difference between what he/she pays for the drug at the out of network pharmacy and the cost that the plan would cover at an in network pharmacy. The documentation does not support an extreme emergency that would require the drug be immediately supplied and the drug could have been received from a network pharmacy. Therefore, we determined that the plan is not required to provide reimbursement for the requested drug.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 and reimbursement for Dextromethorphan syrup to treat the enrollees 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 documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The plan provided claim information for the enrollee indicating the drug at issue was dispensed at a pharmacy not in the plans network on the date the prescription was filled. In these instances, the enrollee may be responsible for paying the difference between what he/she pays for the drug at the out of network pharmacy and the cost that the plan would cover at an in network pharmacy. The documentation does not support an extreme emergency that would require the drug be immediately supplied and the drug could have been received from a network pharmacy. Therefore, we determined that the plan is not required to provide reimbursement for the requested drug.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 Clopidogrel Bisulate 75 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 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 Clopidogrel Bisulate as a self-administered drug in the hospital. 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 Insulin Diclofenac Sodium 1 percent gel 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 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 Diclofenac Sodium as a self-administered drug in the hospital. 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 Insulin Aspart 100 unit per milliliter solution 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 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 Insulin Aspart as a self-administered drug in the hospital. 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 Insulin Glargine 100 unit per milliliter solution 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 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 Insulin Glargine as a self-administered drug in the hospital. 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 Levothyroxine Sodium 100 microgram 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 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 Levothyroxine Sodium as a self-administered drug in the hospital. 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 Levothyroxine Sodium 125 microgram 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 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 Levothyroxine Sodium as a self-administered drug in the hospital. 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 Insulin Lidocaine 5 percent patch 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 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 Lidocaine as a self-administered drug in the hospital. 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 Lidocaine 5 percent patch 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 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 Lidocaine as a self-administered drug in the hospital. 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 Midodrine Hydrochloride 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 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 Midodrine Hydrochloride as a self-administered drug in the hospital. 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 Quetiapine Fumarate 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 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 Quetiapine Fumarate as a self-administered drug in the hospital. 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 Vitamin D3 25 microgram 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 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 Vitamin D3 as a self-administered drug in the hospital. 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 Sublocade 300 milligrams per 1.5 milliliter solution prefilled syringe to treat opioid use disorder, moderate. 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 available documentation.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that all formulary alternatives were tried and failed or were deemed contraindicated. We received additional documentation and included it in the review. 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 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 Nurtec 75 milligram oral disintegrating tablet (ODT) to treat acute migraine without aura and without status migrainosus, not intractable. 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.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.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 Rivastigmine 4.6 milligram per 24 hour patch to treat the enrollee's condition. 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.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 indicate 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 Rybelsus 3 milligram tablet to treat obesity, hypertension and hyperlipidemia. 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 noted conditions are off-label uses for the requested drug. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. Therefore, the drug is being prescribed for non-medically accepted indications.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 a tiering exception request for Stiolto Respimat 2.5/2.5 milligram tablet to treat chronic obstructive pulmonary disease. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Stiolto Respimat is a brand drug on Tier 2 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 Xolair 75 milligram per 0.5 milliliter subcutaneous solution to treat severe persistent allergic asthma. 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.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Vyndamax 61 milligram capsule to treat transthyretin amyloid cardiomyopathy. 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.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, at reconsideration, documentation was given supporting the medical history of heart failure with at least one prior hospitalization for heart failure, evidence of cardiac involvement on echocardiogram with thickened interventricular septum, and 99m Technetium-labeled pyrophosphate cardiac imaging test results positive for TTR amyloid. 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.