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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facet injections and/or oxycodone. With regard to the request for oxycodone, the Centers for Disease Control and Prevention (CDC) issued guidelines for the use of opioid medications in patients with non-cancer related pain for initiation, monitoring, and discontinuation. Specifically, the CDC guidelines state that opioids should only be considered when non-opioid and non-pharmacologic interventions have been ineffective, and when selected, should be used at the lowest dose that is effective and minimize opioid-related complications and risks including overdose. In addition, professional opioid management should include consultation to determine compliance as well as urine toxicology screening and an opioid use contract between the provider and the patient. Per the CDC, providers should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual patient benefits and risks when considering increasing dosage to 50 morphine milligram equivalents or more per day. Based upon the medical documentation submitted for this patient, the total daily morphine equivalent for all opioids is 30 mg. However, the patients records do not meet the requirements of the Medical Board of California (MBC), which states that to assess continued use based on the 5 As which include a) analgesia, b) activity, c) adverse effects, d) aberrance, and e) affect. In this patients case, the 5 As are not being appropriately monitored to ensure continued benefit and compliance per the MBC recommendation. There is report of a pain contract is in place, but the records lack documentation of the patients last urine toxicology screen. In view of the guidelines and clinical documentation submitted for review, the requested oxycodone is not medically necessary for treatment of this patient.With regard to the request for facet joint injections to the lumbar spine, there is medical evidence supporting the safety and efficacy of this treatment modality in well-selected patients. Manchikanti and colleagues reported that, In the lumbar spine, for long-term effectiveness, there is Level II evidence for radiofrequency neurotomy and lumbar facet joint nerve blocks, whereas the evidence is Level III for lumbosacral intraarticular injections. In a subsequent article, Manchikanti and colleagues found that, The level of evidence is II in selecting patients for facet joint nerve blocks at least three months after onset and failure of conservative management, with strong strength of recommendation for physical examination and clinical assessment. In this patients case, there is a lack of documentation of a recent physical examination as recommended by the medical literature to identify facet joint pain and before considering facet joint nerve blocks. Given these findings, the requested facet injections are not medically necessary for treatment of this patient. All told, the requested facet injections and oxycodone are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services and medication are 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 physical medicine and rehabilitation with subspecialty 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.