Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetic Neuropathy. 
Treatment: Oxycontin [oxycodone ER (extended-release)]. 
The insurer denied coverage for Oxycontin (oxycodone ER). 
The denial is upheld. 

This is a patient with a history of diabetic neuropathy. The patient had four years of progressive numbness, throbbing and stabbing in both feet symmetrically. Electromyelogram (EMG)/Nerve Conduction Velocity (NCV) testing performed six months previously revealed a severe neuropathy. The patient was taking Cymbalta 90 milligrams (mg) daily, Lyrica 100 mg three times daily and oxycodone 20 mg three times daily. The patient had been seen in the emergency department for a possible vein issue and did not find any vascular abnormalities. The patient complained of numbness and throbbing in both hands and upper extremity EMG previously revealed bilateral carpal tunnel syndrome, for which the patient underwent carpal tunnel release surgeries in both hands with much improvement and had a potential third surgery plan. The patient had a history of type I diabetes dating from age 14. 

Current medications listed were oxycodone immediate release 20 mg every four hours as needed for pain maximum daily amount 120 mg, oxycodone extended release 80 mg every 12 hours, pregabalin 150 mg three times daily, levothyroxine, topical clobetasol, topical mupirocin and Novolog insulin. Examination revealed slightly limited cervical range of motion, a well healed right-sided horizontal neck scar, mild right triceps atrophy, mild bilateral intraosseous weakness attributed to the patient's generalized peripheral neuropathy, bilateral toe extensor weakness, absent reflexes with trace knee reflexes, flexor plantar responses bilaterally, a stocking-glove sensory loss to light touch, pinprick and temperature from the mid shin and mid forearms ninth to the mid shin and mid forearms, absent proprioception in the toes, absent vibration in the toes and ankles, diminished vibration sensation at the knee, inability to toe, heel or tandem walk, poor toe tapping and pivoting, negative Romberg sign, and normal coordination. The patient underwent EMG/NCV testing, showing an active right cervical radiculopathy. 

Upper extremity EMG/NCV testing was interpreted as revealing electrophysiological evidence of a mild to moderate right C (cervical) 7 radiculopathy with active and chronic features, evidence of a generalized motor axonal peripheral neuropathy with demyelinating and axonal features, and mild chronic changes in the right deltoid consistent with a mild predominantly chronic right C6 radiculopathy. 

EMG/NCV testing of the upper extremities was interpreted as revealing electrophysiological evidence of a generalized sensorimotor predominantly sensory axonal peripheral neuropathy of moderate severity affecting the upper extremities more on the left, significant improvement in the right triceps muscle since the previous study with improvement in the previous seen right C7 radiculopathy and no evidence of an active cervical radiculopathy or brachial plexopathy in the right upper extremity. 

The formulary drugs are not likely to cause the patient an adverse reaction. There is no evidence that the patient has any contraindication due to allergy to any of the formulary drugs. There is no known potential allergy to the formulary drugs. 

The formulary drugs have not been ineffective. There is no evidence that the patient was treated with any medication other than oxycodone ER. 

There is no evidence that oxycodone ER/Oxycontin would be more effective than the formulary drug. 

The carrier's denial of a request for a Formulary Exception for oxycontin (oxycodone ER) is upheld.