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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrocodone 10/325 and Flexeril.Findings:  The physician reviewer found that the guidelines of the Federation of State Medical Boards state that, 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. The Centers for Disease Control (CDC) guidelines for the prescribing of opioids for chronic pain noted that clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. The CDC guidelines also state that nonpharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. In this case, the patient has a history of bipolar disorder, adjustment disorder, and chronic pain related to lumbar radiculopathy. He is status post right knee anterior cruciate ligament reconstruction and left ankle open reduction and internal fixation.  He was treated with opioids for postoperative pain control, which was subsequently tapered. After surgery, the patient reported neuropathic type pain with involvement of the left ankle and foot. MRI findings of the lumbar spine did not reveal a lesion consistent with these symptoms. The nerve conduction study demonstrated findings most consistent with tibial neuropathy. On subsequent visits to his provider, the patient requested additional opioid medications and declined physical therapy as well as other conservative treatment modalities. Per the records, the patient was treated in the emergency department for alcohol and opioid overdose in the past. The records indicate that he has declined nonpharmacological treatment modalities and has requested to be placed on opioid therapy for pain control. Given the history of previous alcohol and opioid overdose, the risks of opioid therapy outweigh any potential benefits. This patient has not exhausted nonpharmacologic therapy and non-opioid pharmacologic therapy. The medical evidence does not support the use of hydrocodone 10/325 in this clinical setting. This medical necessity decision should not be interpreted as a recommendation to stop opioids abruptly, and the patient is advised to speak with the treating provider. Therefore, hydrocodone 10/325 is not medically necessary for the treatment of this patient.A study performed a systematic review of the use of muscle relaxants for low back pain. The authors concluded for people with acute low back pain, muscle relaxants provide clinically significant shortterm pain relief. For chronic low back pain, the efficacy of muscle relaxants is largely unknownProlonged use of these medicines in low back pain cannot be guided by trial evidence. Currently, there is a lack of evidence supporting the use of Flexeril in low back pain and lumbar radiculopathy. Given the history of alcohol and opioid overdose, the risks associated with Flexeril use outweigh any potential benefit. Therefore, Flexeril is 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.