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Summary of Appeals & Independent Review Organization All Other Appeals All other appeals are for drugs not in an inpatient hospital setting that Molina was not able to approve. Sometimes, the clinical information sent to us for these drugs do not meet medical necessity on initial review. When drug preauthorization requests are denied, a member or provider has the right to appeal. Appeals allow time to provide more clinical information. With complete clinical information, we can usually approve the drug. These are considered an appeal overturn. When the denial decision is not overturned, it is considered upheld. Service Code/Drug Name Service Code Description Number of Appeals Number of Appeals Total Appeals Upheld Overturned A9274 EXTERNAL AMB INSULIN DEL SYSTEM DISPOSABLE EA 0 1 1 Abatacept 3 1 4 Abemaciclib 1 0 1 Acalabrutinib 0 1 1 Acne Combination - Two Ingredient 1 0 1 Acyclovir 0 1 1 Adalimumab 7 14 21 Adrenergic Combination - Two Ingredient 1 0 1 Aflibercept 0 2 2 Agalsidase 1 0 1 Alfuzosin 1 0 1 Amantadine 1 0 1 Ambrisentan 0 1 1 Amphetamine 0 1 1 Amphetamine Mixtures - Two Ingredient 1 8 9 Apixaban 7 21 28 Apremilast 12 13 25 Aprepitant 0 1 1 Aripiprazole 5 9 14 ARNI-Angiotensin II Recept Antag Comb - Two Ingredient 6 9 15 Asenapine 0 1 1 Atomoxetine 1 3 4 Atorvastatin 0 1 1 Atovaquone 1 0 1 Axitinib 0 1 1 Azathioprine 0 1 1 Azilsartan 1 0 1 Azithromycin 1 0 1 Baclofen 0 1 1 Baricitinib 1 1 2 Belimumab 0 1 1 Benralizumab 1 0 1 Beta-blockers - Ophthalmic Combination - Two Ingredient 0 2 2 Bimatoprost 0 1 1 Botulinum Toxin 1 4 5 Buprenorphine 4 3 7 Calcifediol 1 0 1 Calcipotriene 1 0 1 Canagliflozin 1 0 1 Caplacizumab 0 1 1 Caplyta 42MG OR CAPS 0 1 1 Cariprazine 1 2 3 Celecoxib 1 4 5 Certolizumab 2 1 3 Cinacalcet 0 1 1 Clonidine 0 1 1 Cobimetinib 1 0 1 Codeine Combination - Two Ingredient 0 1 1 Collagenase 1 0 1 Continuous Blood Glucose Monitor System and/or Supplies 3 4 7 Corticotropin 3 0 3 Cyclosporine 7 12 19 Dalfampridine 1 0 1 Dapagliflozin 1 1 2 Deferasirox 1 0 1 Denosumab 5 1 6 Desvenlafaxine 2 2 4 Deutetrabenazine 1 0 1 Dexlansoprazole 0 2 2 Dextroamphetamine 0 1 1 Diclofenac 4 4 8 Dimethyl Fumarate 0 3 3 Dipeptidyl Peptidase-4 Inhibitor-Biguanide - Two Ingredient 0 1 1 Dronabinol 0 1 1 Dronedarone 1 0 1 Dulaglutide 10 10 20 Duloxetine 0 1 1 Dupilumab 2 5 7 Efinaconazole 1 0 1 Elagolix 3 0 3 Eletriptan 0 1 1 Eltrombopag 0 1 1 Eluxadoline 0 1 1 Empagliflozin 1 1 2 Epoetin 0 3 3 Erenumab 3 2 5 Ertugliflozin 3 1 4 Escitalopram 0 2 2 Esketamine 2 1 3 Etanercept 9 7 16 Evolocumab 4 2 6 Exemestane 1 0 1 Exenatide 1 0 1 Ezetimibe 1 2 3 Febuxostat 2 0 2 Fenofibrate 1 0 1 Fentanyl 0 2 2 Ferumoxytol 1 0 1 Fingolimod 0 2 2 Fluconazole 1 0 1 Fremanezumab 1 3 4 Galcanezumab 1 1 2 Glucose Blood 1 0 1 Guanfacine 1 0 1 Hepatitis C Agent Combination - Two Ingredient 9 5 14 Hydrocodone Combination - Two Ingredient 1 0 1 Hydrocortisone 1 0 1 Hydroxyprogesterone 1 0 1 Icosapent 5 1 6 Imatinib 2 0 2 Imiquimod 0 1 1 Infliximab 0 1 1 Insulin Aspart 1 0 1 Insulin Glargine 2 1 3 Insulin Lispro Protamine & Lispro 0 1 1 Insulin-Incretin Mimetic Combination - Two Ingredient 1 1 2 Isotretinoin 7 3 10 Ixekizumab 2 4 6 J0129 INJ ABATACEPT 10 MG USED MEDICARE ADM SUPV PHYS 1 0 1 J0490 INJECTION BELIMUMAB 10 MG 1 0 1 J0585 BOTULINUM TOXIN TYPE A PER UNIT 3 2 5 J0878 INJECTION DAPTOMYCIN 1 MG 1 0 1 J0885 INJECTION EPOETIN ALFA FOR NON-ESRD 1000 UNITS 1 0 1 J1439 INJECTION FERRIC CARBOXYMALTOSE 1 MG 1 0 1 J1726 INJECTION HYDROXYPROGESTERONE CAPROATE 10 MG 1 0 1 J1745 INJECTION INFLIXIMAB EXCLUDES BIOSIMILAR 10 MG 1 0 1 J2350 INJECTION OCRELIZUMAB 1 MG 0 1 1 J2357 INJECTION OMALIZUMAB 5 MG 1 0 1 J3380 INJECTION VEDOLIZUMAB 1 MG 1 0 1 J3490 UNCLASSIFIED DRUGS 1 0 1 J7320 HYALURONAN/DERIVITIVE GENVISC 850 IA INJ 1 MG 0 1 1 J7321 HYALURONAN/DERIV HYALGAN/SUPARTZ IA INJ PER DOSE 1 1 2 J7325 HYALURONAN/DERIV SYNVISC/SYNVISC-ONE IA INJ 1 MG 0 1 1 J7326 HYALURONAN/DERIV GEL-ONE INTRA-ARTIC INJ PER DOS 1 0 1 J9035 INJECTION BEVACIZUMAB 10 MG 1 1 2 J9041 INJECTION BORTEZOMIB 0.1 MG 0 1 1 J9070 CYCLOPHOSPHAMIDE 100 MG 2 1 3 J9312 INJECTION RITUXIMAB 10 MG 0 3 3 Lamotrigine 0 1 1 Lansoprazole 1 1 2 Lanthanum 0 1 1 Letermovir 1 0 1 Leuprolide 0 2 2 Levalbuterol 1 0 1 Lidocaine 1 0 1 Lifitegrast 3 4 7 Linaclotide 4 3 7 Linagliptin 0 1 1 Liraglutide 1 6 7 Lisdexamfetamine 3 13 16 Lubiprostone 0 2 2 Lurasidone 0 3 3 Macitentan 0 1 1 Mechlorethamine 0 1 1 Mepolizumab 0 1 1 Mesalamine 0 1 1 Methylnaltrexone 1 0 1 Methylphenidate 1 0 1 Metoprolol 1 0 1 Mirabegron 2 2 4 Morphine 1 1 2 Mycophenolate 1 0 1 Nebivolol 0 1 1 Nifedipine 0 1 1 Nintedanib 2 0 2 Nurtec 75MG OR TBDP 1 0 1 Octreotide 0 1 1 Olopatadine 1 0 1 Omalizumab 1 2 3 Ophthalmic Steroid Combination - Two Ingredient 0 1 1 Opioid Combination - Two Ingredient 0 1 1 Otezla 30MG OR TABS 0 1 1 Pancrelipase (Lipase-Protease-Amylase) 0 1 1 Paricalcitol 0 1 1 Paroxetine 0 1 1 Patiromer 3 0 3 Pitolisant 1 0 1 Pomalidomide 0 1 1 Prasugrel 0 1 1 Pregabalin 6 4 10 Prenatal w/o Vit A w/ Fe Carbonyl-Fe Gluconate-DSS-FA-DHA 1 0 1 Q5101 INJECTION FILGRASTIM BIOSIMILAR 1 MCG 0 1 1 QINLOCK 50MG TAB 0 1 1 Quetiapine 1 0 1 Ranolazine 1 0 1 Rifaximin 2 2 4 Riociguat 2 0 2 Risankizumab 4 4 8 Rituximab 0 1 1 Rivaroxaban 7 14 21 Rosuvastatin 5 1 6 Ruxolitinib 1 0 1 Saxagliptin 1 0 1 Secukinumab 5 3 8 Semaglutide 2 6 8 Sevelamer 0 1 1 SGLT2 Inhibitor - DPP-4 Inhibitor Combinations - Two Ingred 0 1 1 Silodosin 0 1 1 Sitagliptin 1 4 5 Sodium Hyaluronate 0 1 1 Sodium Oxybate 0 1 1 Sodium-Glucose Co-Transporter 2 Inhib-Biguanide - Two Ingred 1 2 3 Solifenacin 1 0 1 Sucralfate 0 1 1 Sunitinib 0 1 1 Tacrolimus 1 3 4 Tafluprost 1 2 3 Tapentadol 0 2 2 Telmisartan 0 2 2 Temozolomide 1 1 2 Tenofovir 3 8 11 TEPEZZA 500MG INJ MAINTENANCE DOSE 0 1 1 Tepezza 500MG IV SOLR 0 2 2 Teriflunomide 1 0 1 Thalidomide 1 0 1 Ticagrelor 0 3 3 Tildrakizumab 2 1 3 Tobramycin 0 1 1 Tofacitinib 5 5 10 Tolterodine 1 0 1 Tolvaptan 2 1 3 Tramadol 0 1 1 Tretinoin 2 0 2 Ulcer Anti-Infective w/Bismuth Combination - 3 Ingredient 1 0 1 Ulcer Anti-Infective w/Proton Pump Inhibit -Three Ingredient 1 0 1 Upadacitinib 2 1 3 Ustekinumab 0 1 1 Valbenazine 1 0 1 Valganciclovir 1 2 3 Venlafaxine 0 1 1 Vilazodone 1 1 2 Vortioxetine 0 2 2 Zoledronic Acid 0 1 1 Appeal Grand Totals 295 374 669 Appeals Reviewed by an Independent Review Organization (IRO) When drug preauthorization requests are denied, the member or provider may request that the drug preauthorization request is submitted to an Independent Review Organization (IRO) for review and determination. If an IRO upholds the Molina decision, this means that the drug preauthorization request remains denied by Molina. If the IRO overturns the Molina decision, this means that the IRO decided to approve the drug requested and the preauthorization request will be approved by Molina. Service Code/Drug Name Service Code Description Upheld on IRO Overturned on IRO Total IRO Appeals Apremilast 1 0 1 Botulinum Toxin 1 0 1 Calcifediol 0 1 1 Cariprazine 1 0 1 Dulaglutide 1 0 1 Erenumab 1 0 1 Gabapentin 1 0 1 Hepatitis C Agent Combination - Two Ingredient 1 1 2 Ivabradine 0 1 1 J7321 HYALURONAN/DERIV HYALGAN/SUPARTZ IA INJ PER DOSE 1 0 1 Lamotrigine 1 0 1 Liraglutide 0 1 1 Mirtazapine 1 0 1 Quetiapine 0 1 1 Rivaroxaban 1 0 1 Ticagrelor 1 0 1 Ulcer Anti-Infective w/Proton Pump Inhibit -Three Ingredient 1 0 1 Upadacitinib 1 0 1 Valganciclovir 1 0 1 IRO Appeal Grand Totals 15 5 20 .
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