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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with spinal stenosis and spondylosis. The patient was referred to pain management for evaluation of ongoing low back pain with radiation of pain into the right lower extremity and associated paresthesia. It is noted that the patient was seen by pain management and refused to return to them. The provider also noted trying to explain the harm of being on sleeping pills and pain pills at the same time. The patient is reported as unwilling to change anything and wants to continue the sleeping pills and pain medications at the dosages she was already taking. The patient was prescribed hydrocodone-acetaminophen (Norco) 7.5-325mg, quantity 60, and temazepam (Restoril) 15mg, quantity 10. The patient was seen by pain management where an opioid agreement was discussed with the patient. The patient refused to sign the opioid agreement. The provider recommended steroid injection. Urine drug testing was completed. The patient was administered an epidural injection. The patient has requested authorization and coverage for 120 pills of Norco 10mg and 30 pills of  temazepam 10mg. The Health Plan has denied this request and reported that the requested medications are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination.The patient was prescribed Norco 7.5mg one twice a day maximum, and temazepam 15mg at bedtime. A urine drug screen completed was negative for opioids and benzodiazepines. Epidural injections recommended by the patients provider may not resolve the low back pain immediately. The patient may require more than one injection for improvement. In the interim between epidural injections, she may also require analgesic medication to help with her pain. A non-opioid pain medicine is preferable. Based on the response, that alone may be sufficient, or she may require a short course of Norco or another opioid medicine. The records indicate the patient was prescribed 10 temazepam 15mg pills and 60 Norco 7.5mg pills. Park and colleagues indicate the combined use of opioids and benzodiazepines is known to increase respiratory depression and mortality as they potentiate each others adverse effects. The patients urine drug screen was negative for the prescribed Norco and temazepam. Per the records, she failed to sign a pain contract for opioid medications. The negative urine drug screen, along with failure to sign the pain contract, do not meet Centers for Disease Control (CDC) guidelines for prescription of opioids. Therefore, 120 pills of Norco 10mg and 30 pills of  temazepam 10mg are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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 anesthesiology with sub-specialty 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.