Persius/hicric huggingface dataset:
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 Shingrix vaccine received November 22, 2019 andFebruary 22, 2020. The Plan did not grant this request. We received this case to conduct an independentreview.Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. If an enrolleepays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof ofpayment to ask the Plan to pay its share of the cost. In 2019, the Plan required a $15 for up to a 30 daysupply of a Tier 3 drug purchased from a preferred retail pharmacy. In 2020, the Plan required a $25 for upto a 30 day supply of a Tier 3 drug purchased from a preferred retail pharmacy. The Shingrix vaccine wason the Plan's 2019 and 2020 formulary and was classified as a Tier 3 drug. A request for reimbursementwas submitted to the Plan. In this case, the Plan provided documentation showing that these claims werecovered by the Plan at the time of purchase. The record shows that the Shingrix vaccine receivedNovember 22, 2019 and February 22, 2020 were purchased for an amount that is less than or equal to therequired 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 the Shingrix vaccinereceived November 22, 2019 and February 22, 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 cover Anucort HC. The Plan 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. We determined that Anucort HC is not FDA approved for both safety and effectiveness by checking FDA sources. Therefore, the Plan is not required to cover Anucort HC. 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 usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover and provide reimbursement for Gabapentin Powder, Pentravan Plus EXCream, Ethoxy Diglycol Liquid, Lidocaine Powder, Diclofenac Sodium Powder and Cyclobenzaprine HCLPowder compound purchased at the pharmacy on January 2, 2020 and April 8, 2020. The Plan did not grantthis request. We received this case to conduct an independent review.Medicare Part D does not cover drugs that are not FDA approved. A representative of the pharmacy statedthat bulk powder was used or would be used when compounding the prescription for Gabapentin Powder,Pentravan Plus EX Cream, Ethoxy Diglycol Liquid, Lidocaine Powder, Diclofenac Sodium Powder andCyclobenzaprine HCL Powder compound. Bulk powders used in pharmacy compounding are not reviewedand approved for safety and efficacy by the FDA. Therefore, the Plan is not required to cover or providereimbursement for Gabapentin Powder, Pentravan Plus EX Cream, Ethoxy Diglycol Liquid, LidocainePowder, Diclofenac Sodium Powder and Cyclobenzaprine HCL Powder compound purchased at thepharmacy on January 2, 2020 and April 8, 2020.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Corlanor. 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 Corlanor. The drug is requested to treat inappropriate sinus tachycardia, which is an off-label (non-FDAapproved) use. The Medicare-approved compendia do not contain any citations to support the use of therequested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is notbeing prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptionsrequest based on medical necessity cannot be considered because the requested drug, as prescribed, doesnot meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverageunder Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Corlanor for the diagnosed condition. As a result, the drug isnot being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot becovered under the Medicare Part D benefit for this condition. An exceptions request based on medicalnecessity cannot be considered because this drug, as prescribed, does not meet the definition of a MedicarePart D drug. Therefore, our decision is that the Plan is not required to provide coverage for Corlanor.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Xeljanz XR 11 mg. The Plan did not grant this request. We received this caseto conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Xeljanz XR 11 mg. The drug is requested to treat M05.79 Rheumatoid arthritis with rheumatoid factorof multiple sites without organ or systems involvement. The prescriber sent a statement datedJune 22, 2020, clarifying the medical history. The prescriber states you have tried and failed Methotrexate,Humira and Orencia. Xeljanz XR 11 mg is not on the Plan's formulary. Kevzara, Rinvoq ER and Xeljanz (5mg and 10 mg tablets) are on the Plan's formulary. The prescriber has not indicated why all alternativesrequired by the Plan would likely not be as effective for you as the requested drug; and/or would likelycause adverse reaction(s) or other harm to you. Therefore, an exception to the Plan's coverage criteria is notsupported. Our Physician Reviewer's opinion 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 Xeljanz XR 11 mg.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for Propafenone HCL 150 mg purchased February 25, 2020. 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 required a $131 copayment amount for up to a 90 day supply of a Tier 3 drug purchased in 2020 from a preferred mail order pharmacy. Propafenone HCL 150 mg is on the Plan's 2020 formulary and is classified as a Tier 3 drug. 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 Propafenone HCL 150 mg was purchased February 25, 2020 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 Propafenone HCL 150 mg tab purchased February 25, 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 Shingrix Vaccine purchased on November 12, 2019 and January 28, 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 required a $30.00 copayment for up to a 30 day supply of a Tier 3 drug purchased from a standard retail in 2019 and 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 Vaccine 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 Vaccine purchased on November 12, 2019 and January 28, 2020 from your pharmacy.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Xifaxan. 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 Xifaxan 550 mg. The drug is requested to treat small intestinal bacterial overgrowth, A04.9 Bacterialintestinal infection, unspecified, with abdominal distension and nausea, which is an off-label (non-FDAapproved) use. The Medicare-approved compendia do not contain any citations to support the use of therequested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is notbeing prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptionsrequest based on medical necessity cannot be considered because the requested drug, as prescribed, doesnot meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverageunder Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Xifaxan for the diagnosed condition. As a result, the drug isnot being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot becovered under the Medicare Part D benefit for this condition. An exceptions request based on medicalnecessity cannot be considered because this drug, as prescribed, does not meet the definition of a MedicarePart D drug. Therefore, our decision is that the Plan is not required to provide coverage for Xifaxan.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Xeljanz, 5 mg tablet. The Plan did not grant this request. 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 request for Xeljanz, 5 mg tablet.Xeljanz, 5 mg is requested for ongoing treatment of alopecia universalis, which is an off-label (non-FDA approved) use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Xeljanz, 5 mg tablet for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Xeljanz, 5 mg tablet. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Velphoro . 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 Velphoro 500 mg tablet.The drug is requested to treat hyperphosphatemia associated with end stage renal disease. The prescriberhas not indicated why all alternatives required by the Plan would likely not be as effective for the enrolleeas the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Theprescriber indicated that calcium acetate was not appropriate for a patient with end stage renal disease yet itis approved by the Food and Drug Administration to reduce serum phosphorus in adults with end stagerenal disease as cited in the American Hospital Formulary Service and Drug Information (AHFS-DI), andthe DRUGDEX Information System. Therefore, an exception to the Plan's coverage criteria is notsupported. Our Physician Reviewer's opinion 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 Velphoro.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Lidocaine 5% Patch. The Plan did not grant this request. We received this caseto conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Lidocaine 5% Patch. The drug is requested to treat rotator shoulder pain which is an off-label (non-FDAapproved) use. The Medicare-approved compendia do not contain any citations to support the use of therequested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is notbeing prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptionsrequest based on medical necessity cannot be considered because the requested drug, as prescribed, doesnot meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverageunder Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Lidocaine 5% Patch for the diagnosed condition. As a result,the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, itcannot be covered under the Medicare Part D benefit for this condition. An exceptions request based onmedical necessity cannot be considered because this drug, as prescribed, does not meet the definition of aMedicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage forLidocaine 5% Patch.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan 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 cover Vitamin B12. The Plan did not grant this request. We received this case to conduct an independent review.Medicare law excludes certain drugs from Part D coverage. B12 is one of those excluded drugs because it is a prescription vitamin and mineral product. The record submitted by the Plan does not indicate that they provide supplemental coverage for Vitamin B12. Therefore, the Plan is not required to cover Vitamin B12. 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

You asked the Plan to cover Lyrica 150 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 Lyrica 150 mg.The drug is requested to treat fibromyalgia. The initial request indicated a diagnosis of rheumatoid arthritis.The reconsideration appeal indicated a diagnosis of fibromyalgia and supporting chart notes weresubmitted.For coverage under the prescription drug benefit, Medicare requires that the drug prescribed be used for amedically accepted indication. Our Physician Reviewer found that the Medicare-approved resources docontain citations to support the use of the requested drug for treatment of the noted condition. The productlabel, available at Drugs@FDA, states that Lyrica is indicated for the treatment of fibromyalgia. Therefore,the requested drug is being prescribed for a medically accepted indication.Upon reconsideration, the prescriber states that the enrollee tried and failed treatment with Gabapentin andthat Duloxetine is not appropriate for the enrollee due to use of Trazodone and Donepezil. Additionalmedical information was requested by the Part D QIC. The prescribing physician was asked to address thePlan's additional formulary alternatives. The prescriber has not indicated why all alternatives required bythe Plan would likely not be as effective for the enrollee as the requested drug; and/or would likely causeadverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria isnot supported.Our Physician Reviewer's opinion 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 Lyrica.
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 us as required by Medicare rules because it did not make a timely decision.You asked the Plan to reimbursement for Loratadine 10 mg, Cinacalcet HCL 10 mg, Lanoxin 62.5 mcg, Nepro CarbSteady and Multivitamin received September 17, 2019 and September 18, 2019. The Plan did not grant this request. We received this case to conduct an independent review.Cinacalcet HCL and LanoxinThe Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, you received Cinacalcet HCL and Lanoxin while at the hospital in September 2019. This was an emergency or urgent care situation. You requested reimbursement from the Part D Plan. The request includes proof of payment for the two self-administered drugs. The Plan denied the request for Cinacalcet HCL on the basis that prior authorization was not received. Because this was a hospital stay, you were not in a position to obtain the drugs that had been previously filled at a network pharmacy, nor were they able to obtain prior authorization or off-formulary exception review. Since this was a one-time emergency stay, the Plan should provide an exception to their normal coverage rules. Additionally, the Plan denied the request for Lanoxin on the basis that the National Drug Code (NDC) provided (00173-0242-75) is from a discontinued product. It is reasonable that a hospital would provide self-administered drugs that have been discontinued and/or repackaged.The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to provide coverage and reimbursement for Cinacalcet HCL 10 mg and Lanoxin 62.5 mcg received while at the hospital from September 17, 2019 to September 18, 2019Loratadine, Nepro CarbSteady and MultivitaminMedicare 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 drugs are non-prescription or OTC drugs. Therefore, Loratadine, Nepro CarbSteady and Multivitamin are not eligible for Part D coverage, 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 drug. It only establishes that payment cannot be made under the Medicare Part D benefit.