Persius/hicric huggingface dataset:
Appeal type: Prescription Drug
Decision: Partially Favorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Cyclobenzaprine, Aspirin, Omega-3 Fatty Acid (Fish Oil), Thera, CalciumCarbonate, Cholecalciferol (Vitamin D), and Melatonin purchased from December 22 through December24, 2019, as a patient at the hospital. The Plan did not grant this request. We received this case to conductan independent review.Regarding the request for Cyclobenzaprine: the Part D Plan covers prescriptions filled at an out-of-networkpharmacy only in certain limited circumstances. If an enrollee must use an out-of-network pharmacy, theenrollee will generally have to pay the full cost when the prescription is filled. The enrollee can ask thePlan to reimburse their share of the cost. In this case, the record shows that you were a patient at thehospital from December 22 through December 24, 2019. You received Cyclobenzaprine on December 23and December 24, 2019, for a medical emergency or urgent care. You submitted a request forreimbursement with a copy of the hospital bill and proof of payment.Information in the case record indicates that you were an outpatient at the hospital when you received thisdrug. As such, you were not in a position to obtain the drugs that had been previously filled at a networkpharmacy, nor were you able to obtain prior authorization or off-formulary exception review. Since thiswas a one-time emergency stay, the Plan should provide an exception to their normal coverage rules.The Plan's criteria for out-of-network coverage have now been met. Therefore, our decision is the Plan isrequired to cover and provide any applicable reimbursement for Cyclobenzaprine received from December23 through December 24, 2019, as a patient at the hospital.Regarding the request for Aspirin, Omega-3 Fatty Acid (Fish Oil), Thera, Calcium Carbonate,Cholecalciferol (Vitamin D), and Melatonin: Medicare Part D does not cover non-prescription drugs. Wechecked FDA approved sources for the drugs' classification or determined from other available resourcesthat the drugs are non-prescription or OTC drugs. Therefore, Aspirin, Omega-3 Fatty Acid (Fish Oil),Thera, Calcium Carbonate, Cholecalciferol (Vitamin D), and Melatonin are not eligible for Part Dcoverage, and the Plan is not required to cover or provide reimbursement for them under the Part D benefit.This decision does not address the medical necessity or appropriateness of the requested OTC drugs. It onlyestablishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover or provide reimbursement for Omeprazole 20 mg, Morphine Sulfate 30 mg,Pregabalin 50 mg, Tamsulosin HCL 0.4 mg, Warfarin Sodium 2 mg, Allopurinol 300 mg and AlbuterolSulfate 5 mg/ml received February 15, 2020 through February 17, 2020 while you were a patient in thehospital. The Plan did not grant this request. We received this case to conduct an independent review.The Part D Plan covers prescriptions filled at an out-of-network pharmacy only in certain limitedcircumstances. If an enrollee must use an out-of-network pharmacy, the enrollee will generally have to paythe full cost when the prescription is filled. The enrollee may submit a request for reimbursement withproof of payment to ask the Plan to pay its share of the cost.In this case, the record shows that you were a patient at the hospital from February 15, 2020 throughFebruary 17, 2020. You received Omeprazole 20 mg, Morphine Sulfate 30 mg, Pregabalin 50 mg,Tamsulosin HCL 0.4 mg, Warfarin Sodium 2 mg, Allopurinol 300 mg and Albuterol Sulfate 5 mg/ml for amedical emergency or urgent care. You submitted a request for reimbursement with a copy of an itemizedhospital bill. However, the record does not include proof of payment in full of the self-administered drugportion of the bill. The Plan's criteria for out-of-network coverage and reimbursement have not been met.Therefore, our decision is the Plan is not required to cover or provide reimbursement for Omeprazole 20mg, Morphine Sulfate 30 mg, Pregabalin 50 mg, Tamsulosin HCL 0.4 mg, Warfarin Sodium 2 mg,Allopurinol 300 mg and Albuterol Sulfate 5 mg/ml received February 15, 2020 through February 17, 2020while you were a patient at the hospital.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Farxiga, 10 mg. The Plan did not grant this request. We received this case toconduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Farxiga, 10 mg.The drug is requested to treat Type 2 Diabetes Mellitus. Farxiga is not on the Plan's formulary. Invokana,Jardiance, Invokamet, Glyxambi, and Synjardy are on the Plan's formulary. The prescriber has notindicated why all alternatives required by the Plan would likely not be as effective for the enrollee as therequested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, anexception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is thatformulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requesteddrug is medically necessary, consistent with the prescriber's statement. Based on a review of the availabledocumentation, our Physician Reviewer's opinion is that formulary exception criteria are not met.Therefore, the Plan is not required to cover Farxiga, 10 mg.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Xhance. The Plan did not grant this request. We received this case to conductan independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Xhance. The drug is requested to treat chronic sinusitis and polyp of sinus. Xhance is not on the Plan'sformulary. You have not indicated why all alternatives required by the Plan would likely not be as effectivefor the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to theenrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer'sopinion is that formulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requesteddrug is medically necessary, consistent with the prescriber's statement. Based on a review of the availabledocumentation, our Physician Reviewer's opinion is that formulary exception criteria are not met.Therefore, the Plan is not required to cover Xhance.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for the Estriol Compound purchased March 3, 2020. ThePlan did not grant this request. We received this case to conduct an independent review.Medicare Part D does not cover drugs that are not FDA approved for both safety and effectiveness. Wedetermined that the Estriol Compound purchased March 3, 2020 is not FDA approved for both safety andeffectiveness by checking FDA sources. Therefore, the Plan is not required to cover or providereimbursement for the Estriol Compound purchased March 3, 2020.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Partially Favorable

You asked the Plan to provide reimbursement for Methimazole 5 mg, Baclofen 10 mg, Gabapentin 100 mg,Enalapril Maleate 5 mg, Tizanidine HCL 4 mg and Atorvastatin 40 mg received February 11, 2020 andFebruary 12, 2020 while at the hospital. The Plan did not grant this request. We received this case toconduct an independent review.Baclofen 10 mg, Gabapentin 100 mg, Enalapril Maleate 5 mg and Atorvastatin 40 mgThe Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances.In this case, you were a patient at the hospital in February 2020. This was an emergency or urgent caresituation. During this stay you received several self-administered drugs. The Plan denied the request forreimbursement for Baclofen 10 mg, Gabapentin 100 mg, Enalapril Maleate 5 mg and Atorvastatin 40 mgon the basis that the National Drug Codes (NDCs) for each of these self-administered drugs are not FDAapproved and therefore excluded from Part D coverage. These are all Part D eligible drugs. Additionally,we researched the NDCs for each drug and verified the NDCs are repackaged and/or discontinued. It isreasonable that a hospital would provide self-administered drugs that have been repackaged and/ordiscontinued. Proof of payment is included in the file. Therefore, the Plan's out-of-network coverage ruleswere followed. Therefore, our decision is the Plan is required to provide coverage and reimbursement forBaclofen 10 mg (NDC 52959-0733-10), Gabapentin 100 mg (52959-0757-03), Enalapril Maleate 5 mg(68084-0390-01) and Atorvastatin 40 mg (68084-0099-01) received February 11, 2020 and February 12,2020.Methimazole 5 mg and Tizanidine HCL 4 mgMedicare Part D does not cover drugs that are not FDA approved for both safety and effectiveness. Wedetermined that Methimazole 5 mg and Tizanidine HCL 4 mg (51079-0998-20) are not FDA approved forboth safety and effectiveness by checking FDA sources. The NDC for Methimazole (68084-0275-01) has amarket end date of November 30, 2019 and the NDC for Tizanidine HCL (51079-0998-20) has a marketend date of September 30, 2019; therefore, these are no longer considered FDA approved NDCs. Therefore,the Plan is not required to cover or provide reimbursement for Methimazole 5 mg and Tizanidine HCL 4mg received February 11, 2020 and February 12, 2020.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to provide reimbursement for the Shingrix vaccine and its administration fee receivedMarch 6, 2020. The Plan did not grant this request. We received this case to conduct an independentreview.The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances.In this case, you received the Shingrix vaccine from your prescriber's office. You requested reimbursementfrom the Part D Plan. The Plan denied the request on the basis that proof of payment was not provided. TheShingrix vaccine is a Part D eligible vaccine and the Reconsideration appeal request submitted toMaximus Federal included proof of payment in full for the vaccine and its administration fee. The Plan'sout-of-network coverage rules were followed. Therefore, our decision is the Plan is required to providecoverage and reimbursement for the Shingrix vaccine and its administration fee received March 6, 2020.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Polyethylene Glycol 3350. The Plan did not grant this request. We received this case to conduct an independent review.The Part D Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, you submitted a receipt from the medical center to the Part D Plan. The request was missing several pieces of information including, but not limited to, the date of service, the applicable National Drug Codes, and prescriber's National Provider Identifier number. A representative from MAXIMUS Federal contacted the medical center but was unable to obtain this information. The Plan's out-of-network coverage rules were not followed. Therefore, our decision is the Plan is not required to provide coverage for Polyethylene Glycol 3350.Please note: you may wish to contact the medical center directly and request an itemized statement which includes the above information. Once that itemized statement is received, you may wish to submit that documentation to the Plan in order to process your request.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Repatha Sureclick 140 mg/ml. The Plan did not grant this request. Wereceived this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Repatha Sureclick 140 mg/ml. The drug is requested to treat hyperlipidemia in an enrollee with clinicalatherosclerotic cardiovascular disease. You clarified the medical history in the request for reconsideration.You state the enrollee has intolerance to high dose statins. Medical records were provided from date ofservice April 27, 2020. These medical records document that the enrollee was not able to tolerate Lipitor,Crestor and Pravachol. The records also indicate that the enrollee has now failed Simvastatin. Laboratoryresults were included in the office notes which indicate that the last LDL-C was 184 onDecember 13, 2019. The enrollee satisfies the Plan's coverage criteria. Our Physician Reviewer's opinion isthat prior authorization criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs.Based on the available documentation, our Physician Reviewer's opinion is that prior approval criteria aremet. Therefore, our decision is the Plan is required to cover Repatha Sureclick 140 mg/ml.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Vascepa, 1 gm capsule. The Plan did not grant thisrequest. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor a tiering exception for Vascepa 1 gm.The drug is requested to treat E78.1 Pure hyperglyceridemia. Vascepa, 1 gm is a brand drug on tier 4 of thePlan's formulary. There are no available lower tier brand drugs of the same type on the Plan's formulary totreat the enrollee's condition. Therefore, the drug is not eligible for a tiering exception. Our PhysicianReviewer's opinion is that tiering exception criteria are not met.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of thesame type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in alower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug isbeing used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met becausethere are no lower cost-sharing tiered drugs of the same type for treating the enrollee's condition.Therefore, our decision is the Plan is not required to provide a tiering exception for Vascepa 1 gm capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to cover and provide reimbursement for B12 tablet, Benzonatate 100 mg, Folic Acid 1 mg, Vitamin D2 and Docusate Sodium 100 mg purchased July 4, 2018 through February 10, 2020 at your pharmacy. The Plan did not grant this request. We received this case to conduct an independent review.B12, Folic Acid 1 mg, Vitamin D2:Medicare law excludes certain drugs from Part D coverage. B12 tablet, Folic Acid 1 mg, Vitamin D2 and are those excluded drugs because they are prescription vitamin and mineral products. The record submitted by the Plan does not indicate that they provide supplemental coverage for B12 tablet, Folic Acid 1 mg, Vitamin D2. Therefore, the Plan is not required to cover or provide reimbursement for B12 tablet, Folic Acid 1 mg and Vitamin D2 purchased July 4, 2018 through February 10, 2020 at your pharmacy.Benzonatate:Medicare law excludes certain drugs from Part D coverage. Benzonatate 100 mg is one of those excluded drugs because it is a drug used for the symptomatic relief of coughs and colds. The record submitted by the Plan does not indicate that they provide supplemental coverage for Benzonatate 100 mg. Therefore, the Plan is not required to cover or provide reimbursement for Benzonatate 100 mg purchased February 10, 2020 at your pharmacy.Docusate Sodium:Medicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drug's classification or determined from other available resources that the drug is a non-prescription or OTC drug. Therefore, Docusate Sodium 100 mg, National Drug Code (NDC) 45802-0486-78 purchased February 14, 2019 at your pharmacy is not eligible for Part D coverage, and the Plan is not required to cover or provide reimbursement for it under the Part D benefit. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Shingrix purchased on March 5, 2020, from your pharmacy. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the Plan to pay its share of the cost. The Plan requires a $47 copayment for up to a 30-day supply of a Tier 3 drug purchased from a standard retail pharmacy in 2020. A request for reimbursement was submitted to the Plan. In this case, the Plan provided documentation showing that this claim was covered by the Plan at the time of purchase. The record shows that Shingrix was purchased for an amount that is less than or equal to the required copayment amount. The case record indicates that the Plan provided coverage in accordance with the Part D contract. Therefore, our decision is the Plan is not required to provide reimbursement for Shingrix purchased on March 5, 2020, from your pharmacy.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Motegrity, 2 mg tablet. The Plan did not grant this request. We received thiscase to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Motegrity, 2 mg tablet.The drug is requested to treat constipation. Medical records were provided which support this diagnosis.The prescriber states the enrollee has tried and failed Linzess, Trulance, Miralax, enemas and Amitiza. Theprescriber has not indicated why all alternatives required by the Plan would likely not be as effective for theenrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee.Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinionis that formulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requesteddrug is medically necessary, consistent with the prescriber's statement. Based on a review of the availabledocumentation, our Physician Reviewer's opinion is that formulary exception criteria are not met.Therefore, the Plan is not required to cover Motegrity, 2 mg tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover and provide reimbursement for Benzonatate 100 mg purchased May 7, 2020 atyour pharmacy. The Plan did not grant this request. We received this case to conduct an independentreview.Medicare law excludes certain drugs from Part D coverage. Benzonatate 100 mg is one of those excludeddrugs because it is a drug used for the symptomatic relief of coughs and colds. The record submitted by thePlan does not indicate that they provide supplemental coverage for Benzonatate 100 mg. Therefore, thePlan is not required to cover Benzonatate 100 mg purchased May 7, 2020 at your pharmacy.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Incruse Ellipta. The Plan did not grant this request.We received this case to conduct an independent review.Medicare rules do not require the Part D plan to grant a tiering exception for a brand or biologic drug of thesame type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) ifthe lower tier(s) on the formulary only contain(s) generic alternative drugs. Incruse Ellipta is a Tier 3 branddrug. The lower cost-sharing tier(s) only contain(s) generic alternative drugs. Therefore, our decision is thePlan is not required to provide a tiering exception for Incruse Ellipta.