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

At issue is coverage for Rexulti 0.5 milligram tablet to treat major depressive disorder with psychotic features and anxiety disorder. The Part D plan denied the request for coverage due to a safety check. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee has satisfied the plans safety check. The safety check is in regard to use of Rexulti 0.5 milligram tablet, Fluoxetine Hydrochloride 40 milligram capsule, and Buprenorphine 10 microgram per hour patch. However, the prescriber did not respond to the request.The plan has safety requirements for this drug that must be met before coverage will be provided. The documentation does not clarify the need for the continued use of these drugs, and that the benefit of taking these drugs outweighs the potential risk or why these standards do not apply to this patient. 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 Tacrolimus 0.1 percent ointment. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support a covered diagnosis and that the enrollee has satisfied the plans prior authorization coverage criteria. However, the prescriber did not respond to our request.The Part D plan is responsible for determining whether the requested drug has been prescribed for a medically accepted indication outlined in the Medicare-approved compendia. The submitted documentation does not include medical records or evidence of a prescribed diagnosis. This information was requested by the Part D plan with no response from the prescriber/prescribers office. The documentation submitted at reconsideration also does not include medical records or evidence of a prescribed diagnosis. As such, there is insufficient documentation available to establish that the requested drug has been prescribed for a medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Febuxostat 80 milligram tablet to treat the enrollee's 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 available documentation.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that the enrollee has satisfied the plans prior authorization coverage criteria. However, the prescriber did not respond to our request.The Part D plan is responsible for determining whether the requested drug has been prescribed for a medically accepted indication outlined in the Medicare approved compendia. The submitted documentation does not include medical records or evidence of a prescribed diagnosis. This information was requested by the Part D plan with no response from the prescriber. As such, there is insufficient documentation available to establish that the requested drug has been prescribed for a medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Indomethacin 25 milligram capsule to treat headache, unspecified. The Part D plan auto-forwarded the case to us for review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that all formulary alternatives were tried and failed or were deemed contraindicated. However, the prescriber did not respond to our request. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablet prescribed to treat your 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. Medicare records show that Silver Script Plus is the enrollee's secondary insurance provider. The submitted documentation does not include an Explanation of Benefits (EOB) from the primary insurance for the drug requested. Therefore, we determined that the plan is not required to provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sucralfate 1 gram per 10 milliliter suspension prescribed to treat your condition. 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 correctly to the enrollee at the point of sale. The plans 2023 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira Pen 40 milligrams per 0.8 milliliter prescribed to treat your condition. 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 correctly to the enrollee at the point of sale. The plans 2022 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Acetaminophen. The case was auto forwarded by the Part D plan.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 enrollee is requesting reimbursement for Acetaminophen given as a self-administered drug while as an outpatient in the hospital. Medicare rules state that drug claims must include a valid National Drug Code (NDC) number that is listed with the Food and Drug Administration (FDA). The documentation submitted does not include an NDC number for Acetaminophen. Without the NDC number it cannot be determined if the drug is covered under the Medicare Part D benefit. Therefore, the drug is excluded from coverage under Medicare Part D and not eligible for reimbursement. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Atorvastatin. The case was auto forwarded by the Part D plan.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 enrollee is requesting reimbursement for Atorvastatin given as a self-administered drug while as an outpatient in the hospital. Medicare rules state that drug claims must include a valid National Drug Code (NDC) number that is listed with the Food and Drug Administration (FDA). The documentation submitted does not include an NDC number for Atorvastatin. Without the NDC number it cannot be determined if the drug is covered under the Medicare Part D benefit. Therefore, the drug is excluded from coverage under Medicare Part D and not eligible for reimbursement. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Duloxetine 30 milligram tablet. The case was auto forwarded by the Part D plan.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 enrollee is requesting reimbursement for Duloxetine given as a self-administered drug while as an outpatient in the hospital. Medicare rules state that drug claims must include a valid National Drug Code (NDC) number that is listed with the Food and Drug Administration (FDA). The documentation submitted does not include an NDC number for Duloxetine. Without the NDC number it cannot be determined if the drug is covered under the Medicare Part D benefit. Therefore, the drug is excluded from coverage under Medicare Part D and not eligible for reimbursement. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Fluticasone Propionate. The case was auto forwarded by the Part D plan.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 enrollee is requesting reimbursement for Fluticasone Propionate given as a self-administered drug while as an outpatient in the hospital. Medicare rules state that drug claims must include a valid National Drug Code (NDC) number that is listed with the Food and Drug Administration (FDA). The documentation submitted does not include an NDC number for Fluticasone Propionate. Without the NDC number it cannot be determined if the drug is covered under the Medicare Part D benefit. Therefore, the drug is excluded from coverage under Medicare Part D and not eligible for reimbursement. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Levothyroxine. The case was auto forwarded by the Part D plan.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 enrollee is requesting reimbursement for Levothyroxine given as a self-administered drug while as an outpatient in the hospital. Medicare rules state that drug claims must include a valid National Drug Code (NDC) number that is listed with the Food and Drug Administration (FDA). The documentation submitted does not include an NDC number for Levothyroxine. Without the NDC number it cannot be determined if the drug is covered under the Medicare Part D benefit. Therefore, the drug is excluded from coverage under Medicare Part D and not eligible for reimbursement. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Melatonin. The case was auto forwarded by the Part D plan.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 enrollee is requesting reimbursement for Melatonin given as a self-administered drug while as an outpatient in the hospital. Medicare rules state that drug claims must include a valid National Drug Code (NDC) number that is listed with the Food and Drug Administration (FDA). The documentation submitted does not include an NDC number for Melatonin. Without the NDC number it cannot be determined if the drug is covered under the Medicare Part D benefit. Therefore, the drug is excluded from coverage under Medicare Part D and not eligible for reimbursement. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Pantoprazole 40 milligram tablet. The case was auto forwarded by the Part D plan.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 enrollee is requesting reimbursement for Pantoprazole given as a self-administered drug while as an outpatient in the hospital. Medicare rules state that drug claims must include a valid National Drug Code (NDC) number that is listed with the Food and Drug Administration (FDA). The documentation submitted does not include an NDC number for Pantoprazole. Without the NDC number it cannot be determined if the drug is covered under the Medicare Part D benefit. Therefore, the drug is excluded from coverage under Medicare Part D and not eligible for reimbursement. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Verapamil 80 milligram capsule. The case was auto forwarded by the Part D plan.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 enrollee is requesting reimbursement for Verapamil given as a self-administered drug while as an outpatient in the hospital. Medicare rules state that drug claims must include a valid National Drug Code (NDC) number that is listed with the Food and Drug Administration (FDA). The documentation submitted does not include an NDC number for Verapamil. Without the NDC number it cannot be determined if the drug is covered under the Medicare Part D benefit. Therefore, the drug is excluded from coverage under Medicare Part D and not eligible for reimbursement. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Herpes Zoster Recombinant vaccine prescribed for the enrollee's condition. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the vaccine at the prescriber's office for immunization purposes. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or prescribers office. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement from the prescribers office. However, the enrollees proof of payment in the form of a receipt was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Shingrix 50 micrograms per 0.5 milliliter vaccination. 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 Shingrix was approved and copayment was charged correctly. The plans 2022 Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment/coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trazodone 100 milligram tablet. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The submitted documentation shows the enrollee requests payment for the drug at issue. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Acetaminophen 325 milligram tablet to treat unknown condition. The Part D plan denied the request for coverage and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Acetaminophen is available over the counter without a prescription. Drugs available without a prescription, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from Medicare Part D coverage. Acetaminophen is not eligible for any reimbursement.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 Gabapentin 300 milligram capsule prescribed for unknown 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 requested the plan to provide reimbursement for Oxycodone provided in an out of network hospital. According to the plan's Evidence of Coverage, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, there is missing information needed to consider the request. The documentation provided is not sufficient to provide reimbursement upon review. We are unable to approve your request. We did not receive a detailed receipt from the hospital. For each drug you are asking for a refund, we need the full drug name, quantity, observation status and 11-digit National Drug Code (NDC). The receipt must also show the amount billed and proof of your payment.Therefore, we determined that the plan is not required to reimburse the enrollee without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycodone 5 milligram tablet prescribed for unknown 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 requested the plan to provide reimbursement for Oxycodone provided in an out of network hospital. According to the plan's Evidence of Coverage, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. However, there is missing information needed to consider the request. The documentation provided is not sufficient to provide reimbursement upon review. We are unable to approve your request. We did not receive a detailed receipt from the hospital. For each drug you are asking for a refund, we need the full drug name, quantity, observation status and 11-digit National Drug Code (NDC). The receipt must also show the amount billed and proof of your payment.Therefore, we determined that the plan is not required to reimburse the enrollee without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bexsero suspension prefilled syringe prescribed for unknown diagnosis. 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 submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the requested drug was purchased. The plans Evidence of Coverage states that the enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined this drug was paid correctly and no reimbursement is required by the plan.