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

At issue is Naproxen Sodium 550 milligram tablet prescribed for an unspecified diagnosis. The case was auto-forwarded by the plan.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 Part D plan to provide reimbursement for the requested drug purchased on July 2, 2022 from a network pharmacy, and processed through the enrollee's prior Part D plan, GEHA in error. The enrollee submitted GEHA's overpayment recovery letter, and explanation of benefits (EOB), which includes the copayment amounts paid by the enrollee and the amounts paid by GEHA. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Naproxen Sodium 550 milligram tablet prescribed for an unspecified diagnosis. The case was auto-forwarded by the plan.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 Part D plan to provide reimbursement for the requested drug purchased on March 7, 2022 from a network pharmacy, and processed through the enrollee's prior Part D plan, GEHA in error. The enrollee submitted GEHA's overpayment recovery letter, and explanation of benefits (EOB), which includes the copayment amounts paid by the enrollee and the amounts paid by GEHA. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Naproxen Sodium 550 milligram tablet prescribed for an unspecified diagnosis. The case was auto-forwarded by the plan.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 Part D plan to provide reimbursement for the requested drug purchased on May 31, 2022 from a network pharmacy, and processed through the enrollee's prior Part D plan, GEHA in error. The enrollee submitted GEHA's overpayment recovery letter, and explanation of benefits (EOB), which includes the copayment amounts paid by the enrollee and the amounts paid by GEHA. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Shingrix 50 milligram per 0.5 milliliter injection prescribed for an unspecified diagnosis. The case was auto-forwarded by the plan.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 Part D plan to provide reimbursement for the requested drug purchased on February 21, 2022 from a network pharmacy, and processed through the enrollee's prior Part D plan, GEHA in error. The enrollee submitted GEHA's overpayment recovery letter, and explanation of benefits (EOB), which includes the copayment amounts paid by the enrollee and the amounts paid by GEHA. Therefore, we determined the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aspirin delayed release 81 milligram tablet. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Calcium Carbonate 200 milligram chewable tablet. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Stool Softener laxative 8.6/50 milligram tablet. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amoxicillin 500 milligram capsule prescribed for an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged to the enrollee at the point of sale for 2022 date of fill. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copay amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. We determined the charge of $7.71, which was less than the copay of $10.00 for the date of fill in 2022, was charged correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azithromycin 250 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged to the enrollee at the point of sale for 2022 date of fill. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copay amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. We determined the charge of $7.44, which was less than the copay of $10.00 for the date of fill in 2022, was charged correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is BD Pen Needle Nano 32 gauge X 4 millimeter prescribed for an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 plan submitted documentation that shows the claims for the requested drug were approved and copayment was charged to the enrollee at the point of sale for 2022 date of fill. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copay amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. We determined the copay of $10.00 for the date of fill in 2022 was charged correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buspirone Hydrochloride 5 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 plan submitted documentation that shows the claims for the requested drug were approved and copayment was charged to the enrollee at the point of sale for 2022 dates of fill. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copay amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. We determined the copay of $6.00 for each of the dates of fill in 2022 was charged correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cephalexin 500 milligram capsule prescribed for an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged to the enrollee at the point of sale for 2022 date of fill. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copay amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. We determined the copay of $10.00 for the date of fill in 2022 was charged correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ciprofloxacin Hydrochloride 250 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged to the enrollee at the point of sale for 2022 date of fill. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copay amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. We determined the charge of $5.85, which was less than the copay of $10.00 for the date of fill in 2022, was charged correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ciprofloxacin Hydrochloride 0.3-0.1 percent otic solution prescribed for an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged to the enrollee at the point of sale for 2022 date of fill. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copay amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. We determined the copay the date of fill in 2022 was charged correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dextroamphetamine-Amphetamine 20 milligram capsule prescribed for an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 plan submitted documentation that shows the claims for the requested drug were approved and copayment was charged to the enrollee at the point of sale for 2022 dates of fill. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copay amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. We determined the copay of $20.00 for each of the dates of fill in 2022 was charged correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dicloxacillin Sodium 500 milligram capsule prescribed for an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 plan submitted documentation that shows the claims for the requested drug were approved and copayment was charged to the enrollee at the point of sale for 2022 dates of fill. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copay amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. We determined the copay of $10.00 for each of the dates of fill in 2022 was charged correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Duloxetine Hydrochloride 20 milligram capsule prescribed for an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 plan submitted documentation that shows the claims for the requested drug were approved and copayment was charged to the enrollee at the point of sale for 2022 dates of fill. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copay amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. We determined the charge of $16.82, which was less than the copay of $30.00 for each of the dates of fill in 2022, was charged correctly and no further reimbursement is required by the plan. The date of fill February 4, 2023 for 100 day supply was charged $30.00, which is less than the $35.00 copay and no further reimbursement is due.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocodone/Acetaminophen 5/325 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 plan submitted documentation that shows the claims for the requested drug were approved and copayment was charged to the enrollee at the point of sale for 2022 dates of fill. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copay amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. We determined the copay of $10.00 for the date of fill June 16, 2022 was charged correctly and no further reimbursement is required by the plan. The dates of fill January 4, 2022 and January 6, 2022 were charged $1.00 and $2.50 respectively, which was less than the copay of $10.00 and no further reimbursement is due.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lactulose 10 gram per 15 milliliter solution prescribed for an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 plan submitted documentation that shows the claims for the requested drug were approved and copayment was charged to the enrollee at the point of sale for 2022 dates of fill. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copay amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. We determined the charge of $19.90, which was less than the copay of $20.00 for each of the dates of fill in 2022 was charged correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levofloxacin 750 milligram table prescribed for an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged to the enrollee at the point of sale for 2022 date of fill. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copay amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. We determined the charge of $7.42, which was less than the copay of $10.00 for the date of fill in 2022, was charged correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Losartan Potassium 100 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 plan submitted documentation that shows the claims for the requested drug were approved and copayment was charged to the enrollee at the point of sale for 2022 dates of fill. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copay amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. We determined the copay of $ 9.00 for each of the dates of fill in 2022 was charged correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metronidazole 500 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged to the enrollee at the point of sale for 2022 date of fill. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copay amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. We determined the charge of $7.37, which was less than the copay of $10.00 for the date of fill in 2022 was charged correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Polyethylene Glycol and Electrolytes 100 gram bowel prep solution kit. 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 documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prednisone 20 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged to the enrollee at the point of sale for 2022 date of fill. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copay amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. We determined the charge of $5.00, which was less than the copay of $10.00 for the date of fill in 2022, was charged correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trazodone 100 milligram tablet prescribed for an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.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 plan submitted documentation that shows the claims for the requested drug were approved and copayment was charged to the enrollee at the point of sale for 2022 dates of fill. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copay amount, and minus the difference between the plans approved amount for the drug and what the pharmacy charges. We determined the copay of $9.00 for each of the dates of fill in 2022 was charged correctly and no further reimbursement is required by the plan.