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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees rheumatoid arthritis, complex regional pain syndrome type 2 right leg, and chronic pain syndrome. A review of the record indicates that the enrollee has been diagnosed with chronic pain syndrome, peripheral neuropathy, rheumatoid arthritis (RA), and complex regional pain syndrome (CRPS) type 2 right leg. The records indicated the enrollee has been taking Norco in the past. Medical records indicated the enrollee presented for medication management and has had rheumatoid arthritis. The enrollee reported tingling in the bottoms of the feet and hands and reported pain medications help their neuropathy. The medical records fail to demonstrate lab work or imaging to confirm the RA diagnosis. There is no examination provided to confirm the diagnosis of complex regional pain syndrome. The diagnosis of peripheral neuropathy is due to history only; there is no supporting examination findings or electrodiagnostic studies. There is no assessment of the severity of the pain based on visual analog scale (VAS), improvement in pain due to medication by 30% or functional improvement. She has a signed pain contract. There are no specific guidelines for the treatment of peripheral neuropathy of unknown etiology. The American Academy of Neurology (AAN) performed a systematic review and published guidelines in 2011 for the treatment of painful diabetic neuropathy. They reviewed multiple medications for the treatment of peripheral neuropathy to include `pharmacologic: anticonvulsants, antidepressants, opioids, others; and non-pharmacologic: electrical stimulation, magnetic field treatment, low-intensity laser treatment, Reiki massage, others to reduce pain and improve physical function and quality of life (QOL) in patients with (painful diabetic neuropathy) PDN` . Studies noted, `Pregabalin is established as effective and should be offered for relief of PDN (Level A). Venlafaxine, duloxetine, amitriptyline, gabapentin, valproate, opioids (morphine sulfate, tramadol, and oxycodone controlled-release), and capsaicin are probably effective and should be considered for treatment of PDN (Level B). Other treatments have less robust evidence or the evidence is negative. Effective treatments for PDN are available, but many have side effects that limit their usefulness, and few studies have sufficient information on treatment effects on function and QOL.` In this case, the patient has not had an adequate trial of first line medications. Recent reviews fail to demonstrate that opiates are an effective treatment for peripheral neuropathy. These studies have found significant gaps in research for using opiates in non-cancerous pain, weak support and significant side effects and risk of abuse/misuse. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, allergy and immunology, with subspecialty in rheumatology 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.