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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facet injections and Percocet 10mg (60 per 30 days). The current medical evidence does not support facet injections in this clinical setting. A randomized control trial regarding the use of facet joint blocks concluded that facet blocks are not therapeutic (Cohen, S., et al.). The trial also concluded that higher responder rates in certain treatment groups suggested that facet blocks might provide prognostic value before radiofrequency ablation. American Society of Interventional Pain Physicians (ASIPP) guidelines for interventional techniques in chronic spinal pain stated that the evidence for therapeutic lumbar facet joint blocks is weak. The evidence for lumbar medial branch blocks and subsequent lumbar radiofrequency ablation is moderate to strong and is recommended over the repeated facet joint injections. In this case, the patient has low back pain without radiation into the lower extremities. The patients physical exam findings are notable for lumbar paraspinal tenderness and limited range of motion with lumbar extension. The provider has recommended therapeutic lumbar facet joint blocks, which were done before with some reported relief. As noted above, however, the medical evidence for therapeutic lumbar facet joint blocks is weak, and while facet blocks might provide prognostic value before radiofrequency ablation, they have not been found to be therapeutic in a randomized controlled trial setting. Accordingly, facet injections are not medically necessary to treat the patients medical condition.The submitted documentation supports the medical necessity of Percocet 10mg (60 per 30 days). American Society of Interventional Pain Physicians (ASIPP) guidelines from 2017 state that opioid doses of 40 mg of morphine equivalents are considered low dose therapy, and in this case the requested dosage of two tablets of Percocet 10/325 mg daily fall within this limit. Furthermore, the ASIPP guidelines state that regular checks of the Prescription Drug Monitoring Programs (PDMPs) monitoring system and utilization of urine drug testing be done as part of chronic opioid therapy. In this case, these steps have been followed, and the results have been consistent with the therapy. The providers notes do not express any concerns with regards to irregular or drug seeking behavior by the patient, and the providers notes do not state that there is a concern that the risks associated with opioid therapy outweigh the possible benefits. This is the key criteria set forth in the 2016 CDC guidelines for continuing chronic opioid therapy. The CDC guidelines state that clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient. In this case, the provider notes do not express concern regarding an unfavorable risk/benefit proposition which would compromise the patients safety with continued opioid therapy for the patients chronic low back pain. Under these circumstances, the requested Percocet 10mg (60 per 30 days) is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that a portion of the requested services and medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology, 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.