Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine sulfate ER 45 mg two times daily. The Health Plan has denied this request indicating that the requested medication quantity is not medically necessary for treatment of the enrollees chronic pain syndrome. Findings: The submitted documentation fails to demonstrate the medical necessity of the requested medication quantity in this clinical setting. The step wise World Health Organization ladder for pain relief is considered a reasonable approach for pain control in the palliative and the non-palliative setting. However, in the documentation available for review, there are no objective treatment goals for pain and function noted for the requested medication. In addition, several requirements for opioid prescribing have not been documented as performed, so the need to use them as the primary medication treatment strategy for pain has not been established in this enrolees case. The Centers for Disease Control and Prevention (CDC) state that when opioids are started, providers should prescribe the lowest effective dosage. The CDC states that when starting opioid therapy for chronic pain, clinicians should prescribe immediate release opioids instead of extended release/long-acting (ER/LA) opioids. Moreover, the CDC states regarding co-prescription of opioids with benzodiazepines, epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose. The CDC also states clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible. Clinicians should use caution when prescribing opioids at any dosage and should carefully reassess evidence of the individual benefits and risks when considering increasing dosage to 50 or greater morphine milligram equivalents (MME) per day, and should avoid increasing dosage to 90 or greater MME per day. It is recommended to carefully justify a decision to titrate dosage to 90 or greater MME per day. In this case, the enrollee is taking 80 MME/day. There is no medical evidence based rationale given by the provider or the enrollee for the long term consequences with the continual increase in opioids. Risk and benefit analyses must be performed to justify the requested level of 90 MME/day. It is unclear what the plan is for any unseen future pain results the patient would experience while on 90 MME/day. In addition, dose escalation is not a long term plan but a short term plan for the treatment of tolerance. There are no clear objective goals established by the provider or the enrollee with this high of a dose of opioid. Further, it does not appear that all other non pharmacological ways of taking care of the pain have been performed or addressed. There is no mention of completion of behavior therapy documented despite much research to support its use. Finally, the records have not demonstrated that all non opioid medications have been optimized or tried. For all these reasons, morphine sulfate ER 45 mg two times daily has not been established as medically necessary for the treatment of this enrollees medical condition.Final Result: The reviewer determined that the requested medication quantity is not medically necessary for treatment of the enrollees medical condition. Therefore, the Health Plan denied the requested medication.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.