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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco 10/325 mg 30 tablets per month.The Medical Board of Californias Guidelines for Prescribing Controlled Substances for Pain state that continuation, modification or termination of opioid therapy for pain should be contingent on the providers evaluation of evidence of the patients progress toward treatment objectives and the absence of substantial risks or adverse events. The guidelines state that the method for chronic pain management assessment should take into account whether the patient is experiencing a reduction in pain and whether the patient is demonstrating an improvement in level of function.Centers for Disease Control and Prevention (CDC) guidelines for opioid prescribing for chronic pain state that 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. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. 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 case, the patient suffers from chronic pain due to hidradenitis and has additional pain complaints relating to right shoulder pain, left knee pain, and neck pain. The patient is noted to have a history of taking Norco for pain. The submitted records, however, do not document improvement in function in an objective manner as a result of the patients use of Norco. While the records indicate that Norco allows the patient to remain functional, there is no clear documentation that opioids result in an improvement in pain or functional outcomes. In addition, periodic urine drug testing is not noted in the submitted documentation. Therefore, the requested Norco 10/325 mg 30 tablets per month is not medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat 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 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.