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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Vicodin, 5/300mg for a quantity of 30 tablets. The enrollee has a history of chronic low back and neck pain. X-rays of the neck showed disc degeneration, while a magnetic resonance imaging (MRI) of the neck showed slight progression of degenerative changes that are causing neuroforaminal narrowing from C3-4 to C5-6; and mild spinal stenosis at C4-5. The enrollee underwent right cervical medial branch blocks and had 80% improvement of the pain. He will have radio-frequency ablation. He has seen a pain management physician and has tried anti-inflammatories, muscle relaxants, physical therapy, acupuncture, cervical branch block injections, and a home exercise program. Based on review of the record and reference to the medical literature, it is reasonable and medically necessary to provide the enrollee with Vicodin 5/300mg for a quantity of 30 tablets, which is indicated for moderate to moderately severe pain until the enrollee is re-evaluated after the cervical medial branch radio-frequency ablation is done. Guidelines indicate the use of opioids should be part of a treatment plan. In this case, cervical medial branch radio-frequency ablation is anticipated. The guidelines further indicate a therapeutic trial of opioids should not be employed until the enrollee has failed a trial of non-opioid analgesics. In this case, the enrollee has tried and failed multiple non-opioid analgesics. The literature indicates the use of opioids is not recommended without a thorough evaluation, consideration of alternative medications, treatments, review of all current medications and discussions of risks of opioid therapy and potential interactions with current medications for other conditions. Opioid prescriptions should be for a limited period with the lowest effective dose that provides meaningful pain relief and improved function with manageable side effects. This enrollee has been thoroughly evaluated with consideration and trials of alternative medications and treatments. Lastly, opioids, such as oxycodone (OxyContin) and an acetaminophen/hydrocodone combination (Vicodin), interact with receptors on nerve cells in the body and brain to reduce pain. Opioid pain relievers are generally safe when taken for a short time and as prescribed by a doctor, but because they produce a euphoric effect, there is a chance of addiction. This is why they should be considered a last resort after careful consideration with the treating provider, as has been done in this case.                                                          Final Result: The reviewer determined that the requested service was medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pain management 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 similar medical condition.