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

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for an increase of hydrocodone and morphine. Findings:  The physician reviewer found that dose escalation is not a long term plan but a short term plan for the treatment of tolerance. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in the documentation available for review, no objective treatment goals for pain and function were noted for the requested medication dosage increase. The Centers for Disease Control and Prevention (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. The CDC also states when opioids are started, clinicians should prescribe the lowest effective dosage. The CDC indicates that 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, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to greater or equal to 50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to greater or equal to 90 MME/day or carefully justify a decision to titrate dosage to greater or equal 90 MME/day. In this patients case, she was recently taking 85 MME/day. There is no medical evidence based rationale given for a higher amount of MME/day by the provider or the patient. Risk and benefit analyses must be performed to justify the requested level of 200 MME/day. It is unclear what the plan is for any unseen future pain results the patient would experience while on 200 MME/day. Also, the records indicate that tolerance has taken place since the start of the narcotics. There is no change in objective function noted with the current 85 MME/day. There are no clear objective goals with a higher dose of opioid established by the provider or by the patient. Increases in the past appear to have been done only on the basis of pain levels, which is especially worrisome since not all other non-pharmacological ways of taking care of the pain have been performed. There is no mention of completion of behavior therapy documented, despite much research to support its use. Finally, not all non-opioid medication classes have been optimized or tried. Final Result: The reviewer determined that the requested medication dosage increase 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 anesthesiology with sub-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.