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

Age: 60Gender: FNature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Percocet medication, up to six pills per day/one pill every four hours, for a total of 168 pills for 28 days. On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. The authors further note regarding the prescription of opioids for chronic pain that clinicians should prescribe the lowest effective dosage and use caution when prescribing opioids at any dosage, that the benefits of high-dose opioids for chronic pain are not established, and that there is no difference in pain or function between a more liberal opioid dose escalation strategy and maintenance of current dosage. Additionally, the authors reported that a clinical evidence review found that higher opioid dosages are associated with increased risks for motor vehicle injury, opioid use disorder, and overdose. The Federation of State Medical Boards (FSMB) states, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Further, the FSMB strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. In this case, the patient has chronic pain affecting the lumbar spine and hip due to severe degenerative disease. The records note that the patient has been on chronic high dose opioid therapy for seven years with provider documentation stating only mild improvement in pain interference and quality of life. The provider has initiated a taper of Percocet in conjunction with offering non-opioid treatment alternatives and strategies as suggested by the most recent national guidelines, reporting concern that the risks outweigh the benefits of high dose opioid therapy. Given that this patient is being treated in a manner consistent with current medical literature, the requested medication is not medically indicated. Therefore, Percocet medication, up to six pills per day/one pill every four hours, for a total of 168 pills for 28 days, is not medically necessary for the treatment of this patient. This medical necessity decision should not be interpreted as a recommendation to stop opioids abruptly and the eligible patient is advised to speak with their treating physician. The treating physician and the eligible patient should decide upon an opioid reduction program. It is beyond the scope of the IMR process to specify a specific tapering schedule. The treating physician and the eligible patient are advised to consult the Centers for Disease Control and Prevention (CDC) Guide to Tapering Opioids that provides further opioid weaning guidance.Final Result: The reviewer determined that the requested medication is not medically necessary for the 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.