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

Gender: MNature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nucynta ER. The current medical evidence does not support the requested medication in this clinical setting. The Medical Board of California released a policy statement in November 2014 to provide guidance to providers prescribing controlled substances. The policy statement recommended that providers proceed cautiously (yellow flag warning) once the morphine equivalent dose reaches 80 mg per day. Referral to an appropriate specialist should be considered when higher doses are contemplated. The Centers for Disease Control and Prevention (CDC) guidelines recommend comprehensive steps at all stages of opioid initiation, monitoring, continuation, and discontinuation. The 2016 CDC guidelines indicate 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. An opioid use contract is recommended between the provider and the patient. The guidelines note clinicians should review prescription drug monitoring program (PDMP) data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every three months. Additionally, the CDC noted when prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.In this patients case, the records did not adequately document fulfillment of the above aspects of opioid pain management. It appears that this is a new prescription for the patient. In this case, opioid risk stratification was not documented in the record before starting this opioid therapy. Examples of this included validated measures, such as the Opioid Risk Tool (ORT) or Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R). Querying the Controlled Substance Utilization Review and Evaluation System (CURES) database to monitor for concerning behavior was not documented. The provider indicates that the patient agreed to random urine drug testing, but performance of urine drug testing prior to prescribing the Nucynta ER was not noted.  In sum, the submitted documentation fails to demonstrate the medical necessity of the requested medication. This medical necessity decision should not be interpreted as a recommendation to stop opioids abruptly, and the patient is advised to speak with his treating provider. The treating provider and the patient should decide upon an opioid reduction program.  It is beyond the scope of this review to specify a specific tapering schedule. Therefore, Nucynta ER is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is 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 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.